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Psych > Rosenthal/Sweatman - Somatic Symptoms and Rx > Flashcards

Rosenthal/Sweatman - Somatic Symptoms and Rx Flashcards

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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)
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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
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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
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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
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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
    1. Med AE’s can cause additional symptoms
    2. 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
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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

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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
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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
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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”)
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10
Q

What complications require particular vigilance in somatization disorder?

A
  • Depression
  • Suicidal behavior
  • Alcohol or drug misuse
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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
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12
Q

What is the prognosis for pts with SD?

A
  • Pts who are (+) and cooperative with treatment have very good prospects for improving
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13
Q

What is a neurological disease that can commonly be mistaken for somatic disorder?

A
  • MS
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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
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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
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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)
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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
    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
Q

How might OCD present with somatic complaints?

A
  • 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
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:
    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
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

Psych (11 decks)

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