Lecture 15: Somatoform Disorders Flashcards
What is somatization?
Physical symptoms that may not be fully explained by a known medical diagnosis after appropriate work-up.
It has to cause significant distress and functional impairment.
What is somatization generally described as in terms of response?
It is an OVER response to symptoms.
What are the primary risk factors for somatization?
- Female
- Low socioeconomic status
- Education
- Ethnicity
- Other psych comorbidities
How would we code somatoform disorders in ICD-10 and DSM-V-TR?
- ICD 10: Somatoform Disorders
- DSM-V-TR: Somatic symptom and related disorders
What are the 5 somatoform disorders?
- Somatization disorder/Somatic Symptom Disorder
- Conversion disorder/Functional Neurological Symptom Disorder
- Hypochondriasis/Illness Anxiety Disorder
- Body dysmorphic disorder/same
- Pain disorder/Somatic symptom disorder with predominant pain
Written ICD/DSM-V
What is somatic symptom disorder defined as?
A syndrome of multiple, unexplained physical symptoms.
Who is somatic symptom disorder MC in?
Single females who are poorly educated, non-white, and from a rural area.
What is the classic presentation of somatic symptom disorder?
- Multiple, unexplained physical symptoms, often accompanied by a sense of urgency.
- Long, complicated medical histories
- Multiple invasive diagnostic studies/procedures/treatment
- Often describe themselves as “sickly”.
What are the common systems affected by somatoform disorder?
- GI
- Reproductive
- Neuro
What is the criteria for somatic symptom disorder?
- 1+ somatic symptom that causes distress or significant disruption of daily life.
- Excessive thoughts, feelings, or behaviors related to somatic symptom or associated health concerns manifested by 1+ of the following: disproportionate/persistent thoughts about seriousness of symptoms, persistent high level of anxiety about health/symptoms, excessive time and energy devoted to symptoms/health concerns.
- Patient has symptoms > 6 months
What are the specifiers for somatic symptom disorder?
- With predominant pain
- Persistent (> 6 months)
- Severity (mild, moderate, severe)
What qualifies as severe somatic symptom disorder?
2+ symptoms + multiple somatic complaints or 1 severe complaint
How do we treat somatic symptom disorder?
- Use 1 PCP only
- Frequent followups
- Avoid new/excessive diagnostics
- Psychotherapy primarily
What is conversion disorder?
Altered voluntary or sensory motor function.
What is the MC age that conversion disorder appears?
10-35
What are the etiologies for conversion disorder?
- Trauma
- Comorbid psych disorders
- Low IQ
- Impaired ability to articulate distress
How does conversion disorder typically present?
- Neurologic symptoms that DO NOT correlate with the presence of organic neurologic disease.
- Signs of inconsistency and incongruency
- Hoover’s sign: weakness with hip flexion become strong when contralateral leg is flexed.
- Pseudoseizures, paralysis, blindness, mutism, paresthesia, and anesthesia
Describe Hoover’s sign (image)
What is the DSM-V criteria for Conversion Disorder?
- 1+ symptoms/deficits affecting voluntary motor or sensory function
- Clinical findings incompatible with recognized conditions
- Not better explained by another medical or psychiatric condition
- Causes significant distress, etc.
How do we treat Conversion Disorder?
- Educating about disorder
- Psychotherapy referral (insight-oriented or behavioral therapy)
- Can reverse symptoms
- Discuss treatment of comorbid psych diagnoses
What is illness anxiety disorder characterized by?
Preoccupation with a serious illness with minimal to no somatic symptoms to support this concern.
Who is illness anxiety disorder MC in?
20-30, equal gender.
What is the classic presentation of illness anxiety disorder?
- Predominant concern over the presence of a major disease
- INITIAL: Misinterpretation of benign symptoms
- Extremely detailed histories
- Fixed on one disease or moves to another
- Symptoms wax/wane with stress
- Unswayed by negative objective findings.
What is the DSM-V criteria for illness anxiety disorder?
- Preoccupation with having/acquiring a serious illness.
- Somatic symptoms not present or extremely excessive/disporportionate
- High levels of anxiety regarding health status
- Excessive health-related behaviors or maladaptive violence
- Symptoms >= 6mo
- Not better explained by a different disorder.
What are the two types of health-related behaviors seen in illness anxiety disorder?
- Care-seeking
- Care-avoidant
How is illness anxiety disorder often treated?
- Patients often decline psych referral.
- Frequent, regular visits
- Compassionate, tactful education
- Diagnostic studies only when indicated
- Therapy can be helpful, if pts are willing to go
What characterizes body dysmorphic disorder?
Preoccupations with perceived appearance defects
What do most body dysmorphic disorder patients have in common?
- Unmarried
- Derm/Plastic surgery referrals
What is the classic presentation of body dysmorphic disorder?
- Vague perceptions of their body
- Believe others notice their “flaw” more than reality
- Excessively check mirrors
- Attempts to hide presumed deformity
- Avoid public exposure/interaction
Where are the common “problem” areas for body dysmorphic disorder?
- Facial features
- Hair
- Breasts
- Genitalia
What is the DSM-V criteria for body dysmorphic disorder?
- Preoccupation with 1+ perceived flaw/defect that is NOT observable
- Perform repetitive behaviors or mental acts
- Causes distress
- Can’t have comorbidity like anorexia nervosa
What are the specifiers for body dysmorphic disorder?
- With muscle dysmorphia: small muscle mass
- Good/fair insight: believes the disorder is likely not true.
- Poor insight: believes the disorder is probably true
- Absent insight/delusional beliefs: completely convinced is true.
How do we treat body dysmorphic disorder?
- Correction of perceived flaw is almost NEVER HELPFUL
- SSRIs: off-label but first-line.
- Psychotherapy: CBT, cognitive restructuring with exposure therapy
What is pain disorder?
Subset of somatic symptom disorder with predominant pain.
Who is somatic symptom disorder with predominant pain MC in?
Older women (40-50)
What is the classic presentation for somatic symptom disorder with predominant pain?
- 1+ symptom of pain
- Long hx of medical and surgical care
- Denies any other source of negative emotion and states that if it weren’t for the pain, they would be gucci
- Might have associated medical condition, but psych is far more major
- Symptom not intentionally produced or faked.
What is the DSM-V criteria for somatic symptom disorder with predominant pain?
- 1+ somatic symptom predominantly involving pain that causes distress/disruption.
- Excessive thoughts/feelings about seriousness of symptoms, excessively high levels of anxiety, or excessive time/energy devoted to the symptom.
- Symptoms > 6 mo
How do we treat somatic symptoms disorder with predominant pain?
- NSAIDs ideally
- Opiates if fixed-dose, but avoid usually.
- Antidepressants (preferably SNRIs)
What is factitious disorder?
Faking symptoms to assume “patient” role
What are the general treatment guidelines for all the somatoform disorders?
- Regularly scheduled visits
- Acknowledge and legitimize symptoms
- Reassure
- Educate on how to cope
- Limit diagnostics and referrals
- Functional improvement is the main goal.
What are the two types of Munchausen’s?
- Regular: faking s/s with no external reward
- Munchausen by proxy: intentional inducing symptoms on someone else (abuse)
What is the classic presentation of Munchausen’s?
- Different accounts of illness to different providers.
- Evasive about medical history
- Multiple visits at multiple facilities with multiple providers
- Inducing symptoms intentionally to themselves or proxy.
What is the DSM-V criteria for Munchausen’s?
- Falsification of physical or psychological signs/symptoms.
- Presenting themselves as ill, injured, or impaired.
- Deceptive behavior evident even if no external reward.
- Not explained by a different disorder
What are the red flags with Munchausen’s patients?
- They will be agreeable to extensive workups, but tend to avoid psych referrals.
- Few visitors in hospital
- Often present with zebra symptoms
What does severe Munchausen’s look like?
- Aliases and wandering from hospital to clinic.
- Classically present to ER on night/weekends.
- Failure to respond to standard treatment.
- Upset/angry when confronted.
What is the classic presentation of Munchausen’s by proxy?
Mother inflicting symptoms of illness onto child
What clues might suggest Munchausen’s by proxy?
- Inconsistent history with objective findings
- Recurrent, unexplained illnesses
- No response to standard therapy
- S/s worsen around perpetrator or prior to discharge
- S/s improve with perpetrator is not around
How do we approach treating Munchausen’s?
- Single provider to coordinate care
- Psychotherapy (if agreeable)
- Report if it is by proxy (Abuse!!!!)
What is malingering?
- Intentional faking of S/S for financial gain, drugs, etc.
What is different about how a malingerer approaches treatment/diagnostics vs munchausen’s?
A malingerer avoids diagnostics or therapeutics.
How do we treat a malingerer?
- Avoid being manipulated
- Treat any underlying medical conditions
