somatic disorders

Question 1

somatization

Answer 1

tendency to experience and communicate psychological distress as physical symptoms in absence of identifiable pathology
*symptoms are neither feigned nor under voluntary control of patient, so they seek medical condition bc they think they have a real disease

Question 2

consequences of MUPS (medically unexplained physical symptoms)

Answer 2

psychosocial distress, decreased QOL, inc rates depression and anxiety
medical dangers: invasive procedures, unnecessary surgery, drug trials, cost of care

Question 3

general symptoms of somatic symptom and related disorders

Answer 3

physical sx that may or may not be explained by medical condition
psychosocial stress may or may not = somatic distress
heightened awareness or misinterpretation of normal body functions
not consciously produced or feigned
alexithymia - difficulty expressing emotions verbally

Question 4

general treatment issues of somatic symptom and related disorders

Answer 4

regular follow-ups, brief physical exam at visit, look closely for objective signs of disease, avoid unnecessary tests or treatments, avoid insulting explanations (“all in your head”) but explain that stress can cause symptoms, set limits for contact outside of visits, limit workups to objective findings

Question 5

“psychologization” and somatic symptom and related d/o

Answer 5

may not entirely explain somatization
many patients don’t have other psychiatric conditions, and sometimes physical symptoms don’t respond well to psychological treatments

Question 6

how to approach patients with somatization d/o’s

Answer 6

• set goal as restoration of normal function
• reassure patient that symptoms are common but not serious
• inquire about abuse- up to 2/3 pts have hx of abuse

Question 7

somatoform d/o in DSM5 vs DSM4

Answer 7

5: emphasis on disproportionate affect, behavior, cognition related to physical sx
4: overemphasized centrality of medically unexplained sx

Question 8

somatization d/o criteria

Answer 8

1- hx of physical complaints over several years resulting in tx-seeking or impaired fxn, before 30 yo
2- 4 pain sx, 2 GI sx, 1 sexual sx, 1 pseudoneurological sx
3- sx cannot be explained by known medical condition/substance, or when related to medical condition complaints or impairment&raquo_space; expected
4- sx not intentionally produced or feigned

Question 9

hypochondriasis criteria

Answer 9

1- preoccupied w fears of having serious dz based on misinterpretation of bodily sx
2- persists despite medical evaluation and reassurance
3- beliefs not of delusional intensity
4- distress or impairment
5- at least 6 months
6- not better accounted for by another mental d/o

Question 10

factors contributing to somatic symptom and related d/o

Answer 10

• genetic/biological vulnerability - inc sensitivity to pain
• early traumatic experiences
• learning - gain attention from illness, no reinforcement of non-somatic expressions of distress
• cultural/social norms - stigma of psychological suffering

Question 11

somatic symptom d/o criteria

Answer 11

1- 1+ somatic sx, distressing or impairing
2- excessive thoughts or behaviors related to sx; disproportionate/persistent thoughts about seriousness of sx, persistently high anxiety about sx, or excessive time/energy to sx or health concerns
3- symptomatic (w 1 or multiple sx) for >6 mos

Question 12

risk factors for somatic sx d/o

Answer 12

environmental- lower education, SES, unemployment
gender, age, childhood adversity, chronic physical and/or psychiatric illness
social stress, reinforcing social factors (illness benefits)

Question 13

course of somatic sx d/o

Answer 13

high use of medical care that doesn’t alleviate concerns, multiple doctors seen
unresponsive to interventions, sensitive to medication side effects
feel that care and tx are inadequate

Question 14

illness anxiety d/o criteria

Answer 14

1- preoccupied w having or acquiring serious illness
2- no somatic sx, or mild sx
3- high level of anxiety about health, disproportionate worry about risk for dev dz
4- excessive health-related behaviors or maladaptive avoidance
*at least 6 mos of worries, focus illness may change

Question 15

risk factors for illness anxiety d/o

Answer 15

env: precipitated by major life stress or threat to health, hx childhood abuse or serious childhood illness

Question 16

features supporting diagnosis of illness anxiety d/o

Answer 16

• more frequent in medical vs mental health setting
• consult many physicians for same problem
• medical attention may lead to paradoxical exacerbation of anxiety or iatrogenic complications

Question 17

tx for somatic sx and illness anxiety d/o

Answer 17

reassurance, reattribution (include physical and psych factors), normalization (address patient’s concerns, don’t just say “normal” results)
SSRI, CBT (time-limited)

Question 18

conversion disorder (functional neurological symptom) criteria

Answer 18

1- 1+ sx of altered voluntary motor or sensory function
2- evidence of incompatibility b/t sx and recognized neuro/med conditions
3- sx or deficit not d/t other medical or mental d/o
4- sx or deficit causes distress or impairment or warrants medical evaluation

Question 19

subtypes of conversion d/o

Answer 19

1- motor sx or deficits: involuntary mvmts, tic, seizure, paralysis, weakness
2- sensory sx or deficits: anesthesia, blindness/ tunnel vision, deafness

Question 20

theoretical goals of conversion sx

Answer 20

1- sx produced may provide partial solution to intrapsychic problem or conflict (pt unaware of it)
2- may be unconsciously motivated to play “sick role” and seek associated privileges (release from obligations)

Question 21

risk factors for conversion disorder

Answer 21

temperamental- identification
env- hx child abuse/neglect, stressful life events
physiological- prior medical illness w similar/same sx

Question 22

tx conversion d/o

Answer 22

general: reassurance, physical and occupational therapy
psychotherapies
hypnosis

Question 23

pseudocyesis

Answer 23

false belief of being pregnant a/w objective signs and reported sx of pregnancy including: abd enlargement, reduced menstrual flow, amenorrhea, feeling of fetal mvmt, nausea, breast engorgement/ secretion, labor pains at expected delivery date

Question 24

factitious disorder criteria

Answer 24

1- falsification of physical or psych sx or induction of injury/dz a/w identified deception
2- presents self to others as ill, impaired, injured
3- deceptive behavior evident in absence of external reward for behavior (motivation = sick role)
4- not d/t another mental d/o

Question 25

Munchausen syndrome

Answer 25

10% factitious d/o pts
repeated attempts to obtain hospitalizations following credible and dramatic representation of physical sx
or pseudologia fantastica: pts tell fantastic stories to seek repeated hospitalizations at diff hospitals for simulated or self-induced acute illness

Question 26

Ganser’s syndrome

Answer 26

use of approximate (but wrong) answers to questions that are well understood

Question 27

features supporting dx of factitious disorder

Answer 27

multiple hospital admissions, ease w jargon, current/prior employment in medically-related field, lack of verifiable hx or falsified med records, unexplained findings or scars, failure to respond to typical tx, co-morbid personality d/o (esp borderline) or substance abuse, few interpersonal relationships

Question 28

tx of factitious d/o

Answer 28

early identification, avoid iatrogenesis, sometimes legal intervention required (if kids or elderly affected), address psychiatric dx (rarely allowed by patient)

Question 29

malingering

Answer 29

intentional production of false/ exaggerated physical or psych sx
motivated by external incentives (avoiding military duty/ work, financial compensation, evading prosecution, getting drugs)

Question 30

warning signs of malingering

Answer 30

referred by attorney to clinician for exam, discrepancy between pt claims and objective findings, lack of cooperation during diagnostic evaluation and compliance w tx regimen, presence of antisocial personality d/o