Behavioral science - Somatoform disorders Flashcards
Condition: Conscious production of a physical symptom with unconscious motivations (e.g. : patient wants to assume the “sick” role, but for unrecognized reasons)
Factitious disorder
What are the 5 types of somatoform disorders listed in the DSM5?
Somatization disorder (now Somatic symptom disorder)
Conversion disorder
Body dysmorphic disorder (BDD)
Factitious disorder
Malingering
Illness anxiety disorder - replacement for hypochondriasis (DSM IV only)
Pain disorder (DSM IV only, removed in 5)
What is malingering?
physical symptoms that are consciously produced for conscious motivations (e.g. patient wants to avoid legal, work, or school responsibilities or obtain money)
How is somatization utilized as a defense mechanism?
unconscious expression of an unacceptable emotion as a physical symptom to avoid dealing with that emotion
e.g. You’re unhappy/depressed but instead of addressing it you subconsciously channel the negative feelings into a physical manifestation of chronic pain
Primary gain is motivated by:
Secondary gain is motivated by:
internal/psychic motivations
gaining attention, money, drugs, avoiding responsibility. “I cannot care for myself so you have to.”
Pt. manifests physical illness to draw parents attention away from sibling (to feel like the favorite child)
What type of motivation is this (internal or external)? What type of gain?
External
Secondary gain
When do somatoform disorders usually develop?
Tend to start in early adulthood but reoccur with stress
Who are more affected by somatoform disorders, women or men?
women usually more affected but equal among hypochondriacs
50% of patients with somatoform disorders have co-morbid mental illness. What are two most common?
usually depression/anxiety
T/F somatoform disorders cause impairment in social and/or occupational function
true
T/F Somatization disorder, hypochondriasis, and pain disorder tend to run in families
True
family history of mood disorder or obsessive-compulsive disorder are associated with increased incidence of which two somatoform disorders?
hypochondriasis
pain disorder
somatization disorder incidence is increased in patients with a family history of ______ and ______
antisocial personality disorder and alcoholism
What genetic underpinnings in which neurotransmitter pathways are implicated in development of somatization disorder, hypochondriasis, and pain disorder?
serotonin-related gene pathways (specifically serotonergic hypofunction)
What disorder does this describe?
- ≥4 pain issues
2 gastrointestinal,
1 sexual,
1 neurological symptom
(none can be explained medically) - Onset before 30
- Symptoms tend to be chronic and complete remission is rare
- Unconscious, no secondary gain, patient unaware of behaviors and symptom generation
- causes impairment in social /occupational function
Somatization disorder DSM-IV only (somatic symptom disorder in DSM5)
E.g.
Pain: headache GI: nausea + heartburn Sexual: menstrual irregularities Pseudoneurological: loss of sensation Symptoms may vary by culture
What disorder does this describe?
Sudden and dramatic loss of one or more voluntary motor and/or sensory functions suggesting a neurologic etiology
Preceded by psychological stress or conflict – the presenting symptom tends to have a symbolic relationship with the stressor and serves to decrease anxiety associated with it
- Unconscious, no secondary gain, patient aware of loss and symptom generation
- causes impairment in social /occupational function
Conversion disorder
What is the time course of a conversion disorder? Who is most susceptable to developing one?
Usually self-limited with remission in
These are examples of what disorder?
Seeing something violent = blindness
Shooting someone in self defense = right arm paralysis
Conversion disorder
T/F Course of conversion disorder may be shortened with hypnosis, drug-assisted interviewing
True
What is “La belle indifference” with regard to conversion disorder?
Common feature of condition where patient seems uncaring/unconcerned about their remarkable symptoms
Clinical signs of conversion disorder manifestations:
Wrong dermatomes for sensory loss
Blindness still has optokinetic effects
During seizure can sneeze or react to pain
Pain radiates down instead of up
Seizure head movements are vertical, not horizontal
Shifting paralysis
Globus hystericus - pathognomonic (lump in my throat)
Pseudoseizures
Patients are not pretending - unaware they are generating their physical symptoms
What disorder does this describe?
Fear or idea of having a serious medical illness based on misinterpretation of bodily symptoms
Persists despite negative findings and reassurance after medical work ups
Symptoms persist for ≥6 months
- Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
- causes impairment in social /occupational function
Hypochondriasis (DSM IV only)
Renamed “Illness anxiety disorder” (DSM V)
What differentiates “Illness anxiety disorder” vs “Somatic symptom disorder” in DSM5?
Illness anxiety disorder = high health anxiety without somatic symptoms
Somatic symptom disorder has worry + somatic symptoms
T/F Hypochondriasis/Illness anxiety disorder may have a similar etiology to OCD, GAD and the impulse control disorders – SSRIs may help
True
What disorder does this describe?
Preoccupation with an imagined problem or insignificant abnormality in appearance – usually involving the face or head
Not be accounted for by an eating disorder
Plastic surgery or medical interventions rarely relieve symptoms but are commonplace
- Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
- causes impairment in social /occupational function
Body Dysmorphic Disorder(BDD)
Nose too big/crooked, breasts /body not symmetrical, muscles not symmetrical, too small (adonis complex)
Help me, Mary. You’re my only hope….
Schwartz says: Anorexics are “body dysmorphic” thinking they are overweight
?Does this mean anorexics do or do not have BDD?
What are the criteria for Pain Disorder (DSM IV only)
Protracted pain that is severe enough to cause the patient to seek medical attention
Cannot be explained by physical causes
Acute (
T/F Pain disorder may be related to real but minor medical problem
true
Prior to diagnosis pain disorder, conversion disorder, body dysmorphic disorder, hypochondriasis (Illness anxiety disorder), somatization disorder (Somatic symptom disorder) what should be ruled out?
Unidentified organic illness!
Globus hystericus (cranial nerve disorders), severe neurological pain (spinal arachnoiditis, spinal whiplash), early-stage CT disorders (SLE, RA), CNS (tumors, MS, epilepsy, dementia, stroke), myasthenia gravis, endocrine (hypoglycemia, thyroid abnormalities, porphyria), chronic fatigue syndrome, fibromyalgia
Management for somatoform disorders:
frequent visits (regular, short appts, reassurance,empathy)
identify stressors and motivations for primary gain
treat co-morbid depression / anxiety
Allow face saving opportunities
Refer for non-invasive physical or occupational therapy
T/F SSRIs have been shown to be effective in treatment of hypochondriasis, body dysmorphic disorder, and pain disorder
true
T/F Drug-assisted interviewing with sodium amobarbital or hypnosis may be of help with conversion disorder
true
T/F Psychotherapy, hypnosis, and, interpersonal and cognitive behavioral therapy may be helpful for somatoform disorders
true
Formerly known as Münchausen syndrome
Factitious Disorder
Münchausen syndrome ‘by Proxy’ if you create medical problems in others…
Is factitious disorder a true somatic disorder?
unknown
What is Factitious Disorder?
Conscious feigning or production of physical or mental illness (motivation for behavior is unconscious..)
Get angry and leave quickly when confronted
Motivation is often in order to receive attention from medical personnel – to assume the “sick” role
primary gain = to feel safe and cared for
possible secondary gain = to feel proud, an expert, able to figure things out that doctors cannot
Tends to have a negative impact on work, school, and/or social functioning
T/F Factitious disorder is more common in people who work in the medical field
true
Commonly Feigned or Produced Signs and Symptoms in Factitious Disorder
Abdominal pain (a “grid abdomen” may signify previous unnecessary surgical procedures- this happens with somatic pain disorder too)
Fever (heating a thermometer)
Hematuria (blood from a needle stick)
Seizures (taking excess caffeine, theophylline)
Skin lesions (easily reached areas by chemical dermatitis)
Tachycardia (drug-induced)
Hypoglycemia (insulin injection – look for increased insulin but low C-peptide)
Fever (inject feces)
Deep vein thrombosis (use ligature)
Parent uses chemical to cause skin rash on their child then takes them to the doctor. What disorder is this?
Factitious disorder by proxy is when someone creates medical problems in others.
Typically child abuse.
Must be reported
What is usually the motivation behind factitious disorder by proxy?
gaining attention
parent may have a history of childhood abuse/neglect or serious childhood illness during which he or she felt cared for and protected by medical personnel
Or may like being the expert in his/her child’s care
What is this describing?
Conscious simulation or exaggeration of physical or mental illness to achieve some sort of secondary gain
(Disability, Drugs in the ER, Leave of absence)
Symptoms improve as soon as the secondary gain is obtained
Seen more frequently in the incarcerated and people involved in lawsuits
Malingering (DSM IV only)
T/F Malingering is a psychiatric illness
False
Conscious or not-conscious of producing physical symptoms?
Somatoform Disorders, Factitious Disorders, and Malingering
Not-conscious : Somatoform Disorders
Conscious : Factitious Disorders, and Malingering
Best treatment for somatic-type disorders?
simplify the number of providers, medications, procedures
