SomataformDisorders Flashcards
What does MUPS stand for?
Medically unexplained physical symptoms (MUPS)
Physical symptoms that prompt the suffer to seek health care but remain unexplained after an appropriate evaluation
Somatoform Disorders:
Some authors have suggested that the precise diagnosis given depends more on the diagnosing physician’s specialty than on any actual differences between the syndromes
Consequences of MUPS
impaired physician- patient relationship
- Physician frustration
Patient dissatisfaction
Psychosocial distress
Decreased quality of life
Increased rates of depression and anxiety Increased health care utilization
Types of Somatoform disordres
Smatization disorder, Conversion disorder, Pain disorder, Hypochondriasis, Body Dysmorphic disorder
Presence of physical symptoms that suggest a general medical condition, but are not explained by a medical condition
Psychosocial stress = somatic distress
Misinterpretation of normal physiological functions
Not consciously produced or feigned
Generalities of Somatoform Disorders
Criteria for Somatization Disorder
On exam
Multiple recurring physical complaints that begin before age 30
must have ALL of the following at SOME point
- 4 pain symptoms
- 2 non-pain GI symptoms
- 1 Sexual complain
- 1 pseudoneuro complaint
*not caused by known medical condition
1+ somatic symptom that are distressing or result in significant disruption of daily life
Excessive thoughts, feeling, or behaviors related to the somatic symptoms or associated health concerns as manifested by:
- Disproportionate and persistent thoughts about seriousness of symptoms
- Persistently high level of anxiety about health
- Excessive time and energy devoted to these symptoms
*State of being symptomatic is persistent (typically greater than 6 months)
Somatic Symptom Disorder
Somatic Symptom Disorder is characterized by:
1+ somatic symptom that are distressing or result in significant disruption of daily life
Excessive thoughts, feeling, or behaviors related to the somatic symptoms or associated health concerns as manifested by:
- Disproportionate and persistent thoughts about seriousness of symptoms
- Persistently high level of anxiety about health
- Excessive time and energy devoted to these symptoms
*State of being symptomatic is persistent (typically greater than 6 months)
Somatization disorder Epidemiology
General population: ___
Primary care setting: ___
0.01%
3%
Subsyndromal somatization disorder epidemiology
General population: ___
Primary care setting: ___
11%
20%
Where do we usually dx pts with somatization disorder?
do we see them in psych office?
Patients typically found in general medical setting. RARELY seek psychiatric care
Often refuse psychiatric care due to belief that symptoms are related to undiagnosed primary medical condition.
What does a typical Somatization disorder pt describe themselves?
What do their medical hx look like?
Patients describe themselves as “sickly”
Medical histories are circumstantial, vague, inconsistent and disorganized
Describe complaints in dramatic, exaggerated fashion Large number of outpatient visits
Frequent hospitalizations, Repetitive subspecialty referrals, Large number of diagnoses Multiple medications
What are some key Differential Diagnosis to consider when Dx Somatization Disorder
Primary Medical Disorders!
Disorders with transient nonspecific symptoms
Examples: MS, MG, SLE, AIDS, AIP, endocrine disorders Psychiatric conditions
Other somatoform disorders: Depression, Anxiety
The three features that most suggest a diagnosis of somatization disorder instead of another medical disorder are…
- Involvement of multiple organ systems
- Early onset and chronic course without development of physical signs or structural abnormalities
- Absence of laboratory abnormalities that are characteristic of the suggested medical condition
What are some Somatization Disorder Treament issues
Schedule regular follow-up visits
Perform a brief physical exam focused on the area of discomfort on each visit
Look closely for objective signs of disease rather than taking the patient’s symptoms at “face value”
Avoid unnecessary tests, invasive treatments, referrals and hospitalizations.
Avoid insulting explanations such as “the symptoms are all in your head”
Explain that stress can cause physical symptoms Set limits on contacts outside of scheduled visits
Benefits of Psychothearpy in tx Somatization Disorder
____ to long-term insight oreiented psychotherapy
Short-term dynamic teraphy has show _____
CBT has been shown _____
Not responsive
some efficacy
Effective
What are the outcomes of pts with somatization disorders that use pyschopharm?
antiD limitations in treating, inconsistatn, high rates of discontinue
1 + symptom affecting voluntary motor or sensory symptoms, suggesting neurological disorder, proceeded by acute, identifiable stressor [no longer needs to be proceeded by acute stressor]
Conversion Disorder
*
Clinical findings incompatible with symptom presentation and recognized medical or neurologic illness
1/3 patients have true neurological illness and 25% recur within the first year
“la belle indifference”
Symptoms likely to occur following stress
Symptoms tend to conform to patients understanding of neurology
Inconsistent physical exam
clincal features of conversion disorder
What is the tx for Conversion Disorder?
Conservative: reassure and provide physical and occupation therapy: we feel confident that after 3 sessions w/ PT you will be fully recovered.
Can do psychotherapies and posible Amytal interview
Good and poor prognostic indicators of Conversion disorder
Good: onset following clear stressor, prompt tx, symtoms of paralysis, aphonia and blindness
Poor: delayed tx and symptoms of seizures or tremor
Preoccupation with fears of having a serious illness that does not respond to reassurance after appropriate medical work
Belief not of delusional intensity and is n_ot restricte_d to concern about appearance
Duration of **at least 6 months **
Hypochondriasis
Clincal features of Hypochondriasis
Bodily preoccupation
Disease phobia
Disease conviction
Onset in early adulthood
Chronic with waxing and waning of symptoms
What are the General Apsects of tx of Hypochondriasis?
General aspects
Establishment of trust
History taking
Identification of stressors
Education
What tx therapies are best for Hypochondriasis?
Cognitive Behavioral Therapy
Supportive therapy
Pharmacotherapy: seratonin meds most beneficial
Pervasive feeling of ugliness of some aspect of their appearance despite a normal or nearly normal appearance.
If slight physical anomaly is present, person’s concern is markedly excessive.
Body Dysmorphic Disorder
Clincal apperance of Body dysmporphic disorder
age of onset
appearance preoccupation
Compulsive behaviors
between 15-30 y/o
Apprearace preoccupation of: any body part, most the face/forehead
think about flaws 3-8 hrs/day
compulsive: intent to examine, improve, seek reassurance or hide percieved defect
What Comorbitities and DDx need to be taken into account in persons w/ Body Dysmorphic Disorder
MDD: 60-80%
Social phobia: 38%
Substance use: 36%
OCD: 30%
Personality disorder: 57-100% especially Avoidant
What are the tx options for Body Dysmorphic Disorder
Avoid iatrogenic harm! Dont do corrective surgery, not a cure!
CBT is best
Use SEratonin-specific drgus but takes much longer to improve and at higher doses
Differ from somatoform disorders in that signs and symptoms are INTENTIONALLY PRODUCED
Methods of inducing illness: Exaggerations, Lies Tampering with tests to produce positive results, Manipulations that cause actual physical harm
Deception Syndromes: Factious disorder or Malingereing
*distinguished based on motive
Intentionally exaggerates or induces signs and symptoms of illness.
Motivation is to assume the sick role
External incentives for the illness inducing behavior **are absent **
Factitious Disorder
Prevalence in general population is unknown
Diagnosed in about 1% of patients seen in psychiatric consultation in general hospitals
Possible etiology for Factitious Disorder
hard to tell bc most resist pych intervention. Often suffered childhood abuse and frequent hospitalizations thus hospital was considered safe
Self-enhancement model: may be a means of increasing or protecting self-esteem
10% of factitious disorder patients
Severe and chronic factitious disorder
Pseudologia fantastica (broad, elaborate stories about how they became ill)
Munchausen syndrome (type of Severe Factitious disorder)
A person intentionally produces physical signs or symptoms in another person under the first person’s care
Facticious disorder by proxy
DDx of Facticious Disorder
Must establish the intentional and conscious production of symptoms
Direct evidence Excluding other causes
True physical illness
Other somatoform disorders Malingering
Predisposing factors to Facticious Disorder
True physical disorders in childhood leading to extensive medical treatment
Employment (present or past) as a medical paraprofessional
Severe personality disorder
Borderline personality disorder is the mostprevalent
How do we manage a pt with Facticious Disorder
No specific treatment shown effective
Early identification
Prevent iatrogenesis
Beware of negative countertransference
Be mindful of legal and ethical issues
Address any psychiatric diagnosis underlying the factitious disorder diagnosis
Rarely allowed by the patient
The intentional production of feigning illness
Motivated by external incentives: drugs, litigation, financial compensation, avoidance of work/military, evade criminal prosecution
Malingering
When should you consider a pt has Malingering disorder
Medicolegal presentaiton, marked dsicrepancy btwn persons claimed stress and objective findings, lack of cooperation with eval and tx, antisocial personality disorder
