Rosenthal/Sweatman - Somatic Symptoms and Rx Flashcards
1
Q
What are the medications of choice in somatization? Why? AE’s?
A
- SSRI’s: Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline
- Generally well tolerated, w/no anticholinergic effects, little sedation, and low cardiotoxicity -> considered more acceptable than o/major groups of AD’s with fewer discontinuations
- CAUTION in pts w/seizure disorders (esp. if poorly controlled), in those receiving concurrent ECT, mania, bipolar disorders, diabetes, CV disease, bleeding disorders, anorexia, and in pts w/hx of suicide (INC risk of OD)
2
Q
What is the BBW for the SSRI’s?
A
- INC risk of suicidal thinking and behavior in children, adolescents, and young adults in short-term studies with major depressive disorder (MDD) & o/psychiatric disorders
- Short-term studies showed no INC in risk of suicidality w/AD’s compared to placebo in adults beyond age 24, and there was a reduction in risk w/AD’s compared to placebo in adults 65 and older
- Always take a COMPLETE HISTORY -> have to explore this and DOCUMENT before you prescribe
3
Q
What are the common AE’s of the SSRI’s?
A
- DERM: diaphoresis
- GI: constipation, diarrhea, N/V, xerostomia -> this may be a concern for pts with IBS (serotonin receptors in gut)
- NEURO: dizziness, HA, insomnia, sedated, somnolence, tremor
- PSYCH: agitation
- REPRO: disorder of ejaculation
- OTHER: fatigue
- NOTE: may worry about taking these at night for sleep purposes
4
Q
What should you be worried about with SSRI OD?
A
- SEIZURES: important cx of Citalopram OD, esp. if co-ingested w/drugs known to lower seizure threshold
- In absence of co-ingested drugs, seizures associated w/ingestion of high, supra-clinical Citalopram doses (>400mg)
- Risk should be considered in all pts who attend ED after suspected CITALOPRAM OD, even in absence of pre-existing epilepsy
5
Q
In regards to pharmacology, what do you need to make sure you ask your somatization patients?
A
- CO-EXISTING MEDICATIONS: these pts are often taking unnecessary meds, either prescribed, OTC, or ordered online
- Med AE’s can cause additional symptoms
- Also frequently self-medicate w/alcohol or illegal drugs
- Rigorous review of all meds/substances needed at get-go: pts and caregivers should be warned not to change meds w/o consulting physician
6
Q
Why might pts with somatization disorder by especially liable to AE’s of AD’s? How can you prevent this?
A
- Due to somatic hyper-vigilance
- Initiate low-dose or even sub-therapeutic doses at outset
7
Q
What meds should be avoided in SD pts?
A
- Meds that cause dependency, like tranquilizers
- NOTE: in general with these pts, less medication is better; meds often make matters worse -> AD’s may help if depression is part of the illness
8
Q
How is somatization related to pain meds?
A
- Pts presenting with pain often also present with somatization, and SD is associated with excessive use and non-adherence to meds
- % of pts non-adherent to opioids INC as function of somatization (underuse at all levels, and overuse with severe somatization)
- INC depression and med side effects associated with DEC adherence to opioid prescriptions
9
Q
What are some of the possible drug-drug interactions with SD pts on AD’s?
A
- QT-prolonging drugs: additive risk of arrhythmia -> very small likelihood when given alone, but INC risk when combined w/other drugs that do this
- Drugs affecting serotonin (incl. SJW/Ginkgo): INC risk of serotonin syndrome
- Anticoagulants and NSAID’s: INC risk of bleeding
- Cannabis: INC risk of mania
- Pregnancy: Cat C -> animal studies show adverse effects (esp. Paroxetine)
- Lactation: CONTRA for Citalopram (Sertraline and Paroxetine are “maybes”)
10
Q
What complications require particular vigilance in somatization disorder?
A
- Depression
- Suicidal behavior
- Alcohol or drug misuse
11
Q
How can you best approach mgmt of SD?
A
- Tackle the disorder on a # of fronts
- Psychotherapy tailored to individual needs; involve family members
- Help pt understand how symptoms are caused, look at stresses and factors in pt’s like that could impact symptoms
12
Q
What is the prognosis for pts with SD?
A
- Pts who are (+) and cooperative with treatment have very good prospects for improving
13
Q
What is a neurological disease that can commonly be mistaken for somatic disorder?
A
- MS
14
Q
What are the common elements of the somatic symptom disorders?
A
- Presenting problem is somatic in nature
- Medical illness must be ruled out
- Physical findings are either lacking, or out of proportion to the level of subjective distress
- Common occurrence in primary care
15
Q
What are the 7 somatic symptom and related disorders?
A
- Somatic symptom disorder
- Illness anxiety disorder (formerly called hypochondriasis)
- Conversion disorder: functional neurological symptom disorder
- Psychological factors affecting other medical conditions
- Factitious disorder
- Malingering
- Dissociative disorders
16
Q
What obsessive-compulsive symptoms and features can bring pts to the attention of non-psychiatrists (5)?
A
- Body dysmorphic disorder: desires plastic surgery
- Hoarding disorder: may live in squalor
- Trichotillomania: hair-pulling disorder
- Excoriation: skin-picking disorder
- Body-focused repetitive behavior that causes significant impairment or distress: nail biting, lip chewing
- NOTE: OCD symptoms can also be due to substance abuse/withdrawal, prescribed meds, and other medical disorders (e.g., anorexia nervosa and schizophrenia)
17
Q
What are some “unfounded” symptoms that present in primary care (4)?
A
- Adult ANXIETY disorders (panic disorder): involve somatic symptoms, and lead to search for medical care, but symptoms follow a classic pattern
- SOMATIC symptom disorders: involve unusual, anxious preoccupation with a wide variety of somatic symptoms
- Stress/TRAUMA disorders: often associated with somatic distress -> may require modified approach (trauma informed care)
- OC disorders: seen in plastic surgery, general practice, and dermatology
- NOTE: all of these involve anxious care-seeking, and affect relations with patients and adherence to tx
18
Q
What are the characteristics of somatic symptom disorder?
A
- May start early in life
- Affects mostly WOMEN
- MULTIPLE and shifting somatic symptoms, often dramatically described
- Chaotic life circumstances and history of ABUSE are common
- Medically unexplained, or only marginally explained complaints
- Co(pre)morbid DEPRESSION is common, and often missed
19
Q
What is the prevalence of somatic symptom disorder?
A
- May be as high as 5-7% of general population
- More common in RURAL areas and less educated pts
- Often related to recent stress, history of physical abuse, and/or sexual molestation
- Runs in families
- ALEXITHYMIA: inability to communicate how you are feeling
20
Q
What is alexithymia?
A
- Inability to express feelings in words
- Many pts with “unfounded” somatic complaints are unable to express emotional hurt, fear, anger, etc. in words
- NOT a psychiatric disorder, but a symptom
21
Q
What are the most common somatization symptoms (7)?
A
- Nervousness
- Back pain
- Weakness
- Joint pain
- Dizziness
- Extremity pain
- Fatigue
- OTHERS: nausea, HA, dyspnea, chest pain, abdominal bloating, constipation
22
Q
What should you always consider in pts for whom somatization disorder is in your Ddx?
A
- All of these symptoms can have “REAL” medical causes
- Somatization disorder should be included in the Ddx, esp. if pt has a history of vague and shifting complaints, a thick chart, and a chaotic and stressful life
23
Q
How do SD pts present?
A
- Presenting complaints can involve any of the organ systems
- Urgent and compelling presentation
- Alexithymia: inability to express feeling in words -> pt genuinely unaware of emotional and stressful issues, or their impact
- Often result in unnecessary or unhelpful prescriptions or operations
24
Q
What should be on your Ddx for SD?
A
- Anxiety (panic) disorder, e.g., chest pains
- Illness anxiety disorder: hypochondriasis
- Major depression
- Conversion disorder: neuro symptoms
- Schizophrenia: somatic delusions
- Antisocial personality disorder
- Malingering: lying about symptoms for personal gain
- Factitious disorder: self-inflicted symptoms
- Unrecognized medical problem, i.e., multiple sclerosis (MS), cancer -> these may look like somatic symptom disorder until they get a whole lot worse
- Chronic or acute stress; low pain threshold, stress, anxiety
25
Q
What are the features of illness anxiety disorder?
A
- PREOCCUPATION with having or acquiring a serious illness, often in the absence of symptoms, or with minimal symptoms
- One preoccupation at a time, like HIV, cancer
- Lasts 6 MONTHS or more, and pt cannot be reassured
- Primary concern is the IDEA OF BEING ILL
- If symptoms are present, preoccupation is clearly excessive
- Inability to accept medical verdicts
26
Q
What are the features of conversion disorder?
A
- Symptoms typically LOOK NEUROLOGICAL: paralyses, seizures, tunnel vision, numbness
- Symptoms do not follow known neural pathways
- NOT CONSCIOUSLY FEIGNED
- Causes significant distress or impairment
- Often starts under overwhelming stress: funerals, family arguments, etc.
- About 5% referral to neurology clinics (psych problems being “converted” into medical complaints)
27
Q
What is the treatment for conversion disorder?
A
- First, DO NO HARM; avoid invasive procedures, if possible
- Good news, bad news approach: good news is that you do not have a serious disease, but bad news is this seems to be your body’s way of dealing with stress -> that’s what we need to talk about (allowing you to explore what is going in in the pt’s life)
- Hypnosis, if pt tends to be suggestible
- Family counseling
- Cognitive behavioral therapy (CBT): reinforce healthy behavior and more effective problem-solving
- Physical therapy and CAM approaches have been shown to be quite helpful
28
Q
Is any medical illness affected by psychological factors?
A
- YES: anxiety, tragedy, life stress, abuse, and chaotic circumstances affect development, course, and exacerbation of illness
- Exact location and nature of problem depends on the individual’s vulnerability -> EX: IBS, psoriasis, exacerbation of asthma, MSK pain, etc.
29
Q
What are the features of factitious disorder? Examples?
A
- Pt feigns medical or psych illness, with primary goal of being admitted (or having child admitted) to hospital (overwhelming need to be a pt, or have child or loved one be one, i.e., “by proxy”)
- Irrational
- Behavior occurs in the ABSENCE OF EXTERNAL REWARD OR GAIN
- Pt engages in WILLFUL DECEPTION, but the motivation is not to get money, it is to be an unusual and PUZZLING PT
- This is called PRIMARY GAIN
- EX: self-inflicted infections, faked lab findings (hematuria), claims of mental problems arising from trauma that did not happen
30
Q
What are the features of Muenchhausens’s by proxy?
A
- Factitious disorder imposed on another
- Person imposes feigned illness on another (child, pet, elderly pt); perpetrator given the dx
- Victim may be given an “abuse” diagnosis
31
Q
What are the features of malingering?
A
- Pt feigns illness, but potential rewards are obvious, e.g., insurance money, time off from work, excused absence from school, discharge from jail into hospital care, etc.
- Reward is called SECONDARY GAIN
32
Q
What are the basic features of the dissociative disorders (amnestic states)?
A
- Involve specific medical (cognitive) symptoms related to overwhelming anxiety states
- May look neurological, and deserve a thorough workup
33
Q
What are the 4 dissociative disorders (amnestic states)?
A
- DISSOCIATIVE AMNESIA: sudden amnesia, often related to traumatic experiences
- DISSOCIATIVE FUGUE: sudden unexpected travel with inability to recall one’s past; often, the pts does not know his/her own identity, and is admitted as “Jon Doe”
- DEPERSONALIZATION DISORDER: feeling like one is “on the outside looking in,” related to stress and trauma
- DISSOCIATIVE IDENTITY DISORDER (multiple personality): assuming one of several identities or alters when stressed
- Usually related to childhood trauma
- Controversial dx: some believe this is very real, and others think it is iatrogenic, where pt may have tendency to act strangely at encouragement of therapist
34
Q
How might OCD present with somatic complaints?
A
- Somatic concerns may predominate in:
- Body dysmorphic disorder
- Hypochondriasis (illness anxiety disorder)
- Compulsion may create medical issues in:
- Trichotillomania: hair pulling
- Excoriation: skin picking
35
Q
What are the features of obsessions in OCD?
A
- Recurrent, persistent, and INTRUSIVE thoughts, impulses, or images -> pt cannot ignore or suppress these
- Not simply excessive worries about real-life problems
- Pt recognizes that the thoughts, impulses, images are product of his/her own mind (not imposed from without, as in thought insertion), but feels COMPELLED to act on them
36
Q
What is the difference between delusions and obsessions?
A
- DELUSIONS are unshakeable false beliefs, firmly held
- OBSESSIONS are intrusive thoughts that the pt perceives as unwanted, and often abnormal
37
Q
What are the features of body dysmorphic disorder?
A
- PREOCCUPATION (obsession) with imagined defects of face and body, and compulsion to do something about it
- These patients are:
- Frequent clients of plastic surgeons
- Consumers of “recreational surgery,” like nose jobs, tummy tucks, boob jobs, face lifts, botox, silicone injections
- Usually dissatisfied with results; often start law suits
38
Q
How should you approach a pt presenting with chronic pain?
A
- Pts who complain of pain typically ARE IN PAIN
- If thorough workup fails to reveal a diagnosis, pain is typically MSK in nature, and exacerbated by stress and anxiety
- CAUTION: additive pain meds should be avoided in tx of chronic pain
39
Q
How should you treat somatic symptom disorders?
A
- First, DO NO HARM and encourage healthy living
- Take good psycho-social history, and know the pt as a person
- Screen for depression and anxiety states
- Consider these disorders in Ddx from the beginning, not only after negative test results
- Do NOT get trapped into mind-body dualism: “real pain” or “psychiatric problem”
- Support, boundaries, calm reassurance, regular visits
- Refer for ADJUNCTIVE TXS, such as massage, support group, Tai Chi, biofeedback
- Referral for PSYCHOTHERAPY and/or medication for depression and anxiety may be very appropriate
40
Q
What are some complementary and alternative approaches that should be considered for somatic symptom pts?
A
- Massage (deep tissue and myofascial release) for pain
- Acupuncture (“medical acupuncture”) for pain and nausea
- T’ai Chi (improves mood, balance, and flexibility): esp. helpful to older pts
- Some forms of yoga: CAREFUL -> easy to over-do, esp. if pt is ambitious and overly competitive
- Biofeedback and Relaxation Training for anxiety
- Mindfulness Training for general outlook
- Stress Management for setting limits
- Psychotherapy (CBT) for depression and anxiety
- Meditation and Prayer for calmness
- Dietary and lifestyle changes for general well-being
41
Q
What is the take-home message from this lecture?
A
- Physical complaints and pain can be a primary psychiatric problem, a physical problem, or - most often - a combo of both
