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
What are the features of illness anxiety disorder?
- 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
What are the features of conversion disorder?
- 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
What is the treatment for conversion disorder?
- 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
Is any medical illness affected by psychological factors?
- 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
What are the features of factitious disorder? Examples?
- 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
What are the features of Muenchhausens's by proxy?
- 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
What are the features of malingering?
- 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
What are the basic features of the dissociative disorders (amnestic states)?
- Involve specific medical (cognitive) symptoms related to overwhelming anxiety states
- May look neurological, and deserve a thorough workup
33
What are the 4 dissociative disorders (amnestic states)?
- 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
1. Usually related to childhood trauma
2. 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
How might OCD present with somatic complaints?
- Somatic concerns may predominate in:
1. Body dysmorphic disorder
2. Hypochondriasis (illness anxiety disorder)
- Compulsion may create medical issues in:
1. Trichotillomania: hair pulling
2. Excoriation: skin picking
35
What are the features of obsessions in OCD?
- 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
What is the difference between delusions and obsessions?
- DELUSIONS are unshakeable false beliefs, firmly held
| - OBSESSIONS are intrusive thoughts that the pt perceives as unwanted, and often abnormal
37
What are the features of body dysmorphic disorder?
- PREOCCUPATION (obsession) with imagined defects of face and body, and compulsion to do something about it
- These patients are:
1. Frequent clients of plastic surgeons
2. Consumers of “recreational surgery," like nose jobs, tummy tucks, boob jobs, face lifts, botox, silicone injections
3. Usually dissatisfied with results; often start law suits
38
How should you approach a pt presenting with chronic pain?
- 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
How should you treat somatic symptom disorders?
- 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
What are some complementary and alternative approaches that should be considered for somatic symptom pts?
- 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
What is the take-home message from this lecture?
- Physical complaints and pain can be a primary psychiatric problem, a physical problem, or - most often - a combo of both
