NB11-3 - OCD, Somatic Symptom, and Related Disorders and DLAs

Question 1

What are the diagnostic criteria for obsessive-compulsive disorder (OCD)?

Answer 1

Recurrent obsessions or compulsions that are time consuming or distressful/disruptive and cannot be explained by another disorder.

• Obsessions: intrusive recurrent thoughts, urges, or images that increase distress. These thoughts/beliefs can be of delusional intensity (100% certainty)
• Compulsions: repetitive behaviors/mental acts that are performed to decrease distress (not always logical)

Question 2

What is the specifier added onto the end of a diagnosis when the patient also possesses delusional beliefs?

Answer 2

-with absent insight

ie - OCD with absent insight

Question 3

Descibe the neuroanatomical correlates for OCD. What chemical imbalance could cause this neuroanatomical problem?

Answer 3

There is an overactivity in the cortico-striato-thalamo-cortical (CSTC) circuitry. Basically, it’s the PFC constantly signaling to the motor system to do something because of an obsession.

Could be caused by serotonin deficiency

Question 4

What are the standard OCD treatments?

Answer 4

1. Behavioral therapy - typically exposure and response prevention (ERP) where the patient is exposed to the obsession without allowing them to engage in compulsion.
2. Medications - typically antidepressants that selectively increase serotonin (ie - selective serotonin reuptake inhibitory, aka SSRIs)

Question 5

What are the treatment options for refractory OCD?

Answer 5

Interruption of the CSTC circuitry through:

1. Psychosurgery - surgical (or radiation) lesions of either the anterior cingulate gyrus (cingulotomy) or anterior limb of the internal capsule (capsulotomy)
2. Deep Brain Stimulation - electrical impulses are delivered by an indwelling brain electrode attached to an implanted thoracic pacemaker.

ONLY AFTER THE STANDARD TREATMENTS ARE TRIED

Question 6

Answer 6

D

Question 7

List the major OCD related disorders.

Answer 7

Body Dysmorphic Disorder (BDD)

Hoarding Disorder

Excoriation Disorder

Trichotillomania

Question 8

What are the diagnostic criteria for body dysmorphic disorder (BDD)?

Answer 8

Preoccupation, to the point of functional impairment, with a perceived flaw in physical appearance even though the flaw is mininmal or non-observable. Repetitive behaviors or mental acts are performed in response to the appearance concerns. The belief may be of delusional intensity (-with absent insight).

The preoccupation must not be better accounted for by an eating disorder

Question 9

List the diagnostic criteria for hoarding disorder (HD), excoriation disorder, and trichotillomania.

Answer 9

The following behaviors must cause distress/impairment and must not be better explained by another disorder.

• Hoarding Disorder (HD) - accumulation of possessions in living areas that compromises their intended use
• Excoriation Disorder - recurrent unwanted skin picking causing lesions
• Trichotillomania - recurrent unwanted pulling out of one’s hair

Question 10

List the somatic symptom and related disorders. What is th common feature of these disorders?

Answer 10

• Somatic Symptom Disorder
• Illness Anxiety Disorder
• Conversion Disorder
• Factitious Disorder

The common feature of these disorders is the prominence of somatic/health related symptoms associated with significant distress or impariment.

Question 11

What are the diagnostic criteria for Somatic Symptom Disorder (SSD)?

Answer 11

There are at least one or more distressing/disruptive symptoms Also, there is at least one indicator of excessive thoughts/feelings/behaviors about the symptoms such as:

• Disproportionate thoughts about the seriousness of the symptom
• High levels of anxiety about the symptom or health
• Excessive time/energy devoted to the symptom

A SSD diagnosis is dependant upon the abnormal behaviors/thoughts/feelings and NOT on whether there is a medical explanation for the symptom.

Question 12

What are the diagnostic criteria for illness anxiety disorder (IAD)?

Answer 12

Preoccupation with having/acquiring a serious illness to the point that excessive health related behaviors or maladaptive avoidance is performed despite the fact that somatic symptoms are not present or, if present, are mild and easily explained by:

• A normal physiological sensaion (stomach growl)
• A benign, self-limited dysfunction
• Body discomfort not usually indicative of disease

Question 13

State whether the following are indicative of SSD or IAD:

1. Patient presents with significant abdominal pain related to an ulcer, but worries excessively about having stomach cancer.
2. Patient presents with back pain due to a herniated disk, but the pain is excessive given the medical condition
3. Patient presents with excessive back pain without any physical basis
4. Patient presents with a stomach ache after overeating and is worried about stomach cancer because it runs in the family

Answer 13

1. SSD - real symptom
2. SSD - real symptom
3. SSD - real symptom (remember SSD is not dependant upon a medical explanation)
4. IAD - symptom not usually indicative of disease

Question 14

Why is BDD not also considered to be SSD or IAD?

Answer 14

With BDD the main patient complaint is about appearance, not health.

Question 15

What is a somatic type delusional disorder (DD) and how is it different from an SSD or IAD?

Answer 15

A somatic type DD is a schizophrenia spectrum disorder characterized by a persistent fixed, false belief about body/health to a delusional degree.

In SSD & IAD, the patient is not 100% certain they have something (delusional), they’re just constantly worried they might have something.

Question 16

Answer 16

A

Question 17

Answer 17

C

Question 18

What are the diagnostic criteria for conversion disorder? What is conversion disorder aka?

Answer 18

Patients with conversion disorder, or functional neurological syndrome, have an altered voluntary motor or sensory function despite their being evidence of incompatibility between the symptom and the neurological condition (not just that evidence can’t be found).

Question 19

Do the following patients have conversion disorder:

1. Seizure verified by EEG but no cause found
2. Experiences seizure like episodes with a normal EEG
3. Inability to speak, and the cause has not been identified
4. Inability to speak, and all tests show intact language areas

Answer 19

1. No
2. Yes
3. No
4. Yes

Question 20

What are the diagnostic criteria for factitious disorders? What is this disorder aka? What are this disorders subtypes?

Answer 20

The patient fakes/induces physical or psychological symptoms, in self or others, in the absence of external rewards. Satisfaction for the patient usually is derived from being in the “sick role.” Two subtypes:

• Factitious disorder imposed on self, aka Munchausen’s Syndrome - person feigns symptoms in oneself
• Factitious disorder imposed on another, aka Munchausen’s Syndrome by proxy - person feigns symptoms in another individual

Question 21

What is the differential diagnosis for factitous disorder that should always be considered? What is the diagnostic criteria for this disorder?

Answer 21

Malingering

The patient fakes/induces physical or psychological symptoms in self/others for external rewards (ie - avoiding work/school). There is also malingering by proxy. Complaints typically cease after gaining reward.

Question 22

Answer 22

C

Question 23

Answer 23

Question 24

Answer 24

A

Question 25

What are the possible causes that someone might be experiencing the somatic symptoms associaed with SSD?

Answer 25

1. Physiological factors - overactivity of brain regions involved in processing the unpleasant sensation
2. Cognitive Biases - over attentiveness to somatic symptoms
3. Behavioral Consequences - patient may conform to the sick role (ie - laying in bed) which leads to feeling more ill. Also, unintended benefits may reinforce the patients sick role behavior (ie - more attention, avoiding unpleasant tasks, etc)
4. Psychological Consequences - the patient may be transferring psychological distress into physical symptoms to avoid dealing with the mental distress

Question 26

Why is it important to be extra careful when initiating pyschological care for an SSD patient?

Answer 26

Many SSD patients have only been seeking care for their physical health and may be very resitant, even hostile, towards the idea of seeking pychological help. The best way to go about doing this is to draw attention to the fact that stress over their very real symptoms can actually cause the symptoms to worsen and that psychological help should lessen stress.

Question 27

What are the best methods for treating a person with SSD or related disorders?

Answer 27

Cognitive behavioral therapy to:

• Reduce stress
• Reduce excessive attention to bodily cues
• Correct cognitive distortions about physical symptoms (use statistics and logic)
• Reinfore “non-sick role” behavior (talk to loved ones and have them only be helpful when patient is not acting sick)
• Elucidate and address any emotional basis to the symptom (possible conversion disorder)