Rosenthal/Sweatman - Somatic Symptoms and Rx Flashcards
What are the medications of choice in somatization? Why? AE’s?
- 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)
What is the BBW for the SSRI’s?
- 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
What are the common AE’s of the SSRI’s?
- 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
What should you be worried about with SSRI OD?
- 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
In regards to pharmacology, what do you need to make sure you ask your somatization patients?
- 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
Why might pts with somatization disorder by especially liable to AE’s of AD’s? How can you prevent this?
- Due to somatic hyper-vigilance
- Initiate low-dose or even sub-therapeutic doses at outset
What meds should be avoided in SD pts?
- 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
How is somatization related to pain meds?
- 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
What are some of the possible drug-drug interactions with SD pts on AD’s?
- 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”)
What complications require particular vigilance in somatization disorder?
- Depression
- Suicidal behavior
- Alcohol or drug misuse
How can you best approach mgmt of SD?
- 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
What is the prognosis for pts with SD?
- Pts who are (+) and cooperative with treatment have very good prospects for improving
What is a neurological disease that can commonly be mistaken for somatic disorder?
- MS
What are the common elements of the somatic symptom disorders?
- 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
What are the 7 somatic symptom and related disorders?
- 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
What obsessive-compulsive symptoms and features can bring pts to the attention of non-psychiatrists (5)?
- 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)