Chapter 7 Diagnostic and Statistical Manual of Mental Disorders and Pain Management Flashcards
KEY POINTS 1. Somatoform disorders involve somatic complaints that cannot be explained by any general medical or neurologic condition, the effects of a substance, or a culturally sanctioned behavior. 2. Somatization disorder is a polysymptomatic entity beginning before 30 years of age, extending over a period of years, and is characterized by a constellation of pain, gastrointestinal, sexual, and pseudoneurologic symptoms. 3. Undifferentiated somatoform disorder involves one or more physical
What are the Somatoform Disorders?
- Complex Somatic Symptom Disorder (previously known under somatization or pain disorder +/- hypochondriasis)
- Illness anxiety disorder (previously hypochondriasis)
- Functional Neurological Disorder (previous conversion disorder)
Somatization
described as a tendency to experience and communicate somatic distress and symptoms
unaccounted by pathologic findings, to attribute them to physical illness, and to seek medical help for them
Differential Diagnosis of Somatic Symptom Disorder
unrecognized organic disease, anxiety, substance abuse,
cognitive dysfunction, and psychosis
Essential Features of Somatic Symptom Disorder
one or more somatic symptom(s) that are distressing and/or result in impairment of daily life
Diagnostic criteria of Complex Somatic Symptom Disorder
A) One or more somatic symptom(s) that are distressing or result in significant impairment of daily life
B) Excessive thoughts, feelings or behaviours related to the somatic symptoms that are:
- Disproportionate and persistent thoughts about the seriousness of the symptoms
- persistently high levels of anxiety about health or symptoms
- excessive time and /or energy devoted to the symptoms
C) Duration > 6 months
Diagnostic Criteria for Illness Anxiety Disorder
A) a preoccupation with having or acquiring a serious illness
B) Somatic symptoms are not present, or mild in intensity
C) High levels of anxiety, easily agitated or alarmed
D) Excessive health-related behaviour
E) Duration >6 months
Diagnostic Criteria for Functional Neurological Disorder
A) one or more symptoms affecting voluntary motor function, sensory function or transient loss of consciousness
B) Not due to a medical condition, effects of a substance or culturally sanctioned behaviour
C) One or more diagnostic inconsistency or incongruity with a neurological or medical disorder
D) Causes significant distress and impairment
Common criteria to both factitious disorder and malingering
the intentional production of physical and/or psychological symptoms
Factitious Disorder
Deliberately producing, feigning or exaggerating symptoms without evidence of gain from it.
Diagnostic criteria for Factitious disorder
A) The falsification of psychological or physical signs or symptoms, or induction of disease or injury associated with the identified deception
B) The individual presents to others as injured, ill, or impaired
C) the deceptive behaviour is apparent even in the absence of external incentives
D) the behaviour is not better explained by another mental disorder
Malingering
Intentional falsification of physical and/or psychological symptoms is motivated by external factors (e.g., economic gain, avoiding legal responsibility, avoiding military service, or avoiding domestic duties)
Clues that suggest a diagnosis of malingering include
- Medicolegal context of the presentation
- Discrepancy between self-report and medical findings
- Poor patient cooperation
- Antisocial Personality Disorder
“malingering by proxy”
A parent fabricating an illness in his or her child, again for the purpose of external gain (such as social benefits)
Successful identification of the malingering patient remains difficult. Waddell’s Signs maybe useful. What are they?
Tenderness:
- Superficial: light pinching causing pain = positive
- Nonanatomic: deep tenderness over a wide area= positive
Simulation:
- Axial loading: downward pressure on the head causing low back pain = positive
- Rotation: examiner holds shoulders and hips in the same plane and rotates patient; pain= positive
Distraction:
- Straight leg raise causes pain when formally
tested, but straightening the leg with hip flexed 90° does not
Regional:
- Weakness: multiple muscles not enervated by the
same root.
- Sensation: glove and stocking loss of sensation
Overreaction:
- Excessive show of emotion
Illness Anxiety Disorder Diagnostic Criteria
A) a preoccupation with acquiring or having a serious illness
B) somatic symptoms are not present, or only mild in intensity
C) High levels of anxiety, easily agitated or alarmed
D) Excessive health-related behaviour
E) Duration >6 months
What are the subtypes of Illness Anxiety Disorder?
- Care-seeking type
2. Care-avoidant type
What are the medical conditions which need to be considered as Differential Diagnoses to Complex Somatic Symptom Disorder
HIV
Endocrinopathies
Myasthenia Gravis
Multiple Sclerosis
What are the 11 criteria of Substance Use Disorder
- Taking the substance in larger amounts or for longer then you meant to
- Wanting to cut down or stop using, but not managing to
- Spending a lot of time getting, using or recovering from using the substance
- Cravings and urges to use the substance
- Not managing to do what you should at work/home/school because of substance use
- Continuing to use, despite problems in relationships
- Giving up important social/occupational/ recreational activities because of substance use
- Continuing to use even when it puts you in danger
- Continuing to use, despite the knowledge it causes or worsens physical or psychological disorders
- tolerance (needing more to get the desired effect)*
- Development of withdrawal symptoms when not taking the substance.*
- not when used appropriately under medical guidance
How do you determine severity of Substance use disorder?
Mild - 2-3 criteria met
Moderate - 4-5 criteria met
Severe - >6 criteria met
What is a definition of Post Traumatic Stress Disorder
Feelings of hopelessness, intense fear, vulnerability, loss of safety, and loss of control following an overwhelming experience or witnessed life-threatening event.
What are the criteria for Post Traumatic Stress Disorder?
TRAIN!
Trauma/Stressor - direct exposure, witnessed trauma, or learning a close friend or relative was exposed to trauma
Reactivity/arousal - agitation, risky behaviour, hypervigilance, difficulty sleeping or difficulty concentrating
Avoidance - of trauma-related thoughts or external reminders
Intrusive Symptoms - upsetting memories, nightmares, flashbacks, emotional distress, or physical reactivity after reminders of trauma
Negative cognition or mood - inability to recall, overly negative thoughts, exaggerated blame of self or others, negative affect
The Symptoms must cause significant distress or functional impairment
Not explained by medications, substances or organic/medical conditions.
What are the diagnostic criteria for Generalised Anxiety Disorder?
A) Excessive anxiety and worry, about a number of events or activities, occurring on most days for more than 6 months
B) Difficult to control the worry or anxiety
C) Associated with 3 or more:
- restless/keyed up / on edge
- easily fatigued
- difficulty concentrating/ mind goes blank
- irritability
- muscle tension
- sleep disturbance (difficulty falling or staying asleep, or unsatisfying sleep)
D) Symptoms cause distress/impairment in social/occupational or other areas of function
E) Not attributable to the psychological effects of a substance or medical condition
What are the diagnostic criteria for Major Depressive Disorder?
A) 5 or more within the same two week period, as a change from previous
- depressed mood*
- anhedonia*
- significant weight loss/gain
- insomnia/hypersomnia nearly every day
- psychomotor agitation/retardation nearly every day
- fatigue/loss of energy nearly every day
- worthlessness/guilt nearly every day
- reduced concentration/ indecisiveness
- recurrent thoughts of death/suicidal ideation +/- plan
B) Symptoms cause significant distress or impairment in social/occupational function
C) not attributable to physiological effects of a substance or medical condition
D) Not better explained by schizophrenia or psychotic disorder
E) Never had a manic or hypomanic disorder
What are the diagnostic criteria for Adjustment disorder?
Emotional or behavioural symptoms in response to a stressor (which may be positive) within 3 months of its onset plus:
1) Marked distress out of proportion to the intensity of the stressor
2) Significant impairment in functioning
After termination of the stressor (or its consequences), symptoms persist for no longer than an additional 6 months
What are the subtypes of Adjustment Disorder?
- with depressed mood
