Lec 84 Somatic Symptoms

Question 1

How do you categorize somatoform disorders?

Answer 1

by level of conscious/unconscious motivation

by level of conscious/unconscious symptoms

Question 2

What is malingering?

Answer 2

pt consciously fakes disorder in order to attain specific [external] gain like avoiding work, obtaining compensation

Question 3

What is a factitious disorder?

Answer 3

pt consciously creates physical/psych symptoms in order to assume “sick role” to get medical attention [internal gain]

Question 4

What is somatoform disorder?

Answer 4

physical symptoms with no identifiable physical cause, both illness production and motivation are unconscious drives; symptoms not intentionally produced or feigned

Question 5

What are DSM criteria for somatic symptom disorder?

Answer 5

• one or more somatic symptoms [including pain] that are distressing or cause significant disruption daily life
• excessive thoughts, feelings, behaviors related to somatic symptoms as manifested by:
• persistent thoughts about seriousness of symptoms
• high level anxiety about health
• excess time/energy devoted to health concerns

state of being symptomatic persists > 6 mo although any one symptom may not be continuous

Question 6

What are some common behaviors in somatic symptom disorder?

Answer 6

• high level worry of illness even when evidence to contrary
• health concerns = central role in life, feature of identity
• high level med care utilization
• may seek care from multiple docs for same symptoms
• often unresponsive to med interventions
• may refuse mental health referral

Question 7

What is epidemiology of somatic symptom disorder?

Answer 7

female > males
prevalence 5-7%
common in lower SES

Question 8

What is course of illness somatic symptom disorder?

Answer 8

begins in adolescence through mid 20s
chronic illness with fluctuations in freq and diversity
rarely totally remits

Question 9

If you see pt < age 30, many physical complaints over period of years and result in treatment being sought or significant impairment in functioning
- multisystem symptoms

Answer 9

somatic symptom disorder

Question 10

What is differential diagnosis somatic symptom disorder?

Answer 10

MS, SLE, hemochromatosis, psych disorders, malingering

Question 11

What is etiology of somatic symptom disorder?

Answer 11

unconscious need to be ill = symptoms are learned behavior and way of controlling environment

• chaotic lives, history of abuse, inability to verbalize distress
• co-morbid with personality disorder, antisocial PD, alc dependence
• cognitive deficits suggest bilateral frontal lobe dysfunction
• difficulty information processing = “hysterical”

Question 12

What are genetics of somatic symptom disorder?

Answer 12

• diagnosed in 20% of female 1st degree relative women w/ disorder

Question 13

What is treatment for somatic symptom disorder?

Answer 13

prevent adoption of sick role

regularly scheduled appts with consistent reassurance

limit invasive tests, avoid unnecessary meds

treat co-morbid psych disorders
sensitive referral for psychotherapy

Question 14

What is conversion disorder?

Answer 14

• one or more symptoms of altered voluntary motor or sensory function = sudden loss of function [paralysis, blindness, mutism]
• often following acute stressor
• pt aware but may be indifferent toward symptoms

symptoms involuntary, often respond to suggestion

initiation/exacerbation preceded by conflicts/stressors

not limited to pain or sexual dysfunction

Question 15

35 year old woman who presents with acute onset blindness after walking in on husband with another woman

What should you think?

Answer 15

conversion disorder

Question 16

22 year old man who develops atypical chest pain on the anniversary of his father’s death from an MI. Admitted to CCU, where he can grieve and at same time be excused from the demands of his ongoing life

What should you think?

Answer 16

conversion? or malingering?

Question 17

What are some types of presentations that can occur in conversion disorder?

Answer 17

motor = weakness/paralysis, abnormal movement

sensory = altered sensation, vision, hearing

abnormal generalized limb shaking with loss of consciousness

episodes of unresponsiveness

Question 18

What is epidemiology of conversion disorder?

Answer 18

females, adolescents, young adults

lower SES/education
lack of psychological sophistication

Question 19

What is course of conversion disorder?

Answer 19

onset anytime through lifespan = usually late adolescence/early adulthood

acute/self-limited, usually resolve by discharge; 25% relapse w/in 1 yr

better prognosis for blindness/paralysis; worse for seizure/tremor

single episode usually 1 symptoms but longitudinally can have other conversion symptoms

Question 20

What is differential for conversion disorder?

Answer 20

MS, myasthenia gravis, polio, epiletpiform seizure, guillain barre, other myopathies

• factitious disorder or malingering if definite evidence of feigning

Question 21

What is etiology of conversion disorder?

Answer 21

• history of childhood abuse/neglect

- limbic areas might override activation motor/sensory cortices

Question 22

What is treatment for conversion disorder?

Answer 22

treat co-morbid psych illness
rule out physical illness
give reassurance/relaxation
direct confrontation not recommended
deal with underlying conflict/interpersonal relationships

Question 23

What is factitious disorder?

Answer 23

motivation presumed to be unconscious, related to desire to assume sick role

consciously create physical/psych symptoms to assume “sick role” and get medical attention

external incentives for the behavior absent [economic gain, avoid legal responsibility, etc]

usually reject psych interventions

Question 24

What is etiology of factitious disorder?

Answer 24

women > men
age 20-40s
may have health related jobs or training
high prevalence co-morbid psych disorders –> malingering, substance abuse, PD

desire to receive empathetic support

early childhood abuse, emotional deprivation

triggered by recent stressor

unusually seeking invasive tests

Question 25

What is munchausen?

Answer 25

chronic factitious disorder wtih physical signs and symptoms
characterized by history multiple hospital admissions and willingness to receive invasive procedures

co-morbid with antisocial PD

single males, 40s

Question 26

What is treatment for fictitious disorder?

Answer 26

avoid neg rxns toward pt
psych consult, delicate confrontation, collaborative treatment
psychotherapy
treat comorbid disodrers

Question 27

What is munchausen syndrome by proxy [factitious disorder imposed on another]

Answer 27

• falsification psycholigcal signs/symptoms in another
  indicidual presents another to others as ill, impaired, injured even in absence of obvious external rewards

motivation = sick role by proxy = form of child/elder abuse

Question 28

Is malingering a psychiatric disorder?

Answer 28

nope!

Question 29

How do you treat malingering?

Answer 29

understand motivations for symptom production

be prepared for defensive rxn

family/educational/occupational interventions may reduce motivation to malinger

Question 30

What is hypochondriasis?

Answer 30

pre occupation with fear of having serious disease based on misinterpretation of body signs/symptoms

belief not of delusional intensity and not restricted to concern about appearance

equal men/women

Question 31

What is functional disorder?

Answer 31

medically unexplained symptoms