Lec 84 Somatic Symptoms Flashcards
How do you categorize somatoform disorders?
by level of conscious/unconscious motivation
by level of conscious/unconscious symptoms
What is malingering?
pt consciously fakes disorder in order to attain specific [external] gain like avoiding work, obtaining compensation
What is a factitious disorder?
pt consciously creates physical/psych symptoms in order to assume “sick role” to get medical attention [internal gain]
What is somatoform disorder?
physical symptoms with no identifiable physical cause, both illness production and motivation are unconscious drives; symptoms not intentionally produced or feigned
What are DSM criteria for somatic symptom disorder?
- 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
What are some common behaviors in somatic symptom disorder?
- 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
What is epidemiology of somatic symptom disorder?
female > males
prevalence 5-7%
common in lower SES
What is course of illness somatic symptom disorder?
begins in adolescence through mid 20s
chronic illness with fluctuations in freq and diversity
rarely totally remits
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
somatic symptom disorder
What is differential diagnosis somatic symptom disorder?
MS, SLE, hemochromatosis, psych disorders, malingering
What is etiology of somatic symptom disorder?
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”
What are genetics of somatic symptom disorder?
- diagnosed in 20% of female 1st degree relative women w/ disorder
What is treatment for somatic symptom disorder?
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
What is conversion disorder?
- 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
35 year old woman who presents with acute onset blindness after walking in on husband with another woman
What should you think?
conversion disorder
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?
conversion? or malingering?
What are some types of presentations that can occur in conversion disorder?
motor = weakness/paralysis, abnormal movement
sensory = altered sensation, vision, hearing
abnormal generalized limb shaking with loss of consciousness
episodes of unresponsiveness
What is epidemiology of conversion disorder?
females, adolescents, young adults
lower SES/education
lack of psychological sophistication
What is course of conversion disorder?
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
What is differential for conversion disorder?
MS, myasthenia gravis, polio, epiletpiform seizure, guillain barre, other myopathies
- factitious disorder or malingering if definite evidence of feigning
What is etiology of conversion disorder?
- history of childhood abuse/neglect
- limbic areas might override activation motor/sensory cortices
What is treatment for conversion disorder?
treat co-morbid psych illness rule out physical illness give reassurance/relaxation direct confrontation not recommended deal with underlying conflict/interpersonal relationships
What is factitious disorder?
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
What is etiology of factitious disorder?
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
What is munchausen?
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
What is treatment for fictitious disorder?
avoid neg rxns toward pt
psych consult, delicate confrontation, collaborative treatment
psychotherapy
treat comorbid disodrers
What is munchausen syndrome by proxy [factitious disorder imposed on another]
- 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
Is malingering a psychiatric disorder?
nope!
How do you treat malingering?
understand motivations for symptom production
be prepared for defensive rxn
family/educational/occupational interventions may reduce motivation to malinger
What is hypochondriasis?
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
What is functional disorder?
medically unexplained symptoms
