Somatic Sx and Related Disorders

Question 1

DSM V:

Somatic Symptom and Related Disorders

Answer 1

All disorders in this category share a common feature:

The prominence of somatic symptoms associated with significant distress and impairment.

A characteristic of many of these disorders is not just somatic sx but the way they interpret them, incorporating cognitive affective and behavioral responses.

The disorders are more likely to be seen in PCP and medical settings rather than Psychiatric settings

Question 2

Somatic Symptom Disorder

Definition

Answer 2

• One or more somatic symptoms that are distressing
• Excessive thoughts, feelings, or behaviors related to somatic symptoms or associated health concerns
  
  • Persistent thoughts about the seriousness of sx
  • High levels of anxiety about health or sx
  • Excessive time or energy devoted to sx
• Pain may be the predominant presenting symptom

Question 3

Somatic Symptom Disorder

Etiology

Answer 3

• Social communication
  
  • Pain is a way of telling people around them that they are not doing well
• Symptoms substitute repressed instinctual impulses
• Faulty perception / interpretation of sensory inputs
  
  • Normally filtered by the RAS, some people have defective RAS
• Alexithymia
  
  • Inability to express your emotional symptoms
    
    • Possible defect in corpus callosum
  • Not all cultures have the language to communicate psychological stress/symptoms and so psych symptoms may present as physical symptoms
• Cultural Factors
  
  • You can adopt the role of a sick person

Question 4

Somatic Symptom Disorders

Management

Answer 4

• Course of the illness is chronic and debilitating
• Stress associated with exacerbations
• Patients are helped by a single primary physician
• “Care” rather than “cure” approach
• Regular visits
• Avoid medical work ups
• Psychotherapy
• Psychotropic if indicated

Question 5

Illness Anxiety Disorder

Answer 5

• Preoccupation with having or acquiring an illness
• High levels of anxiety
• Easily alarmed about health issues
• Excessive health related behaviors (repeatedly checks body for signs of illness) or maladaptive avoidance (avoids doctor appointments)
• Hypochondriasis in DSM IV

Question 6

Somatic Symptom Disorder

Vs

Illness Anxiety Disorder

Answer 6

Somatic Symptom Disorder is present when there are significant somatic symptoms

Illness Anxiety Disorder there are minimal somatic symptoms, but patients are primarily concerned with the idea that they are ill

Question 7

Anxiety Illness Disorder

Management

Answer 7

• Illness is often lifelong with periodic exacerbation
• Starts in early or middle adult life
• Treat associated anxiety and depression
• Group therapy

Question 8

Conversion Disorder

Definition and Presentation

Answer 8

(Functional Neurological Symptom Disorder)

• Criteria:
  
  • One or more symptoms of altered motor or sensory symptoms
  • between symptoms and recognized medical / neurological conditions
  • Deficit causes distress
• Common presentations:
  
  • Weakness or paralysis
  • Abnormal movements – tremors, gait disturbance, myoclonus
  • Swallowing symptoms
  • Speech symptoms – slurred speech, dysphonia
  • “Seizures” aka pseudoseizures
  • Anesthesia or sensory loss

Question 9

Conversion Disorder

Epidemiology

Answer 9

• Hysteria
• ? 5-10% of general hospital consults
• Women > Men 2:1 to 10:1
• Any age, but more common in adolescents and young adults
• More in rural populations vs. urban population
• Associated with: Major depression, Personality disorders – histrionic, dependent

Question 10

Conversion Disorder

Etiology

Answer 10

• Psychoanalytic: Unconscious intrapsychic conflict and conversion of anxiety into a physical symptom
• Learned behavior
  
  • Patients who present with seizure disorder may have family members with seizures where they have learned how to act
• ? Biological factors
  
  • Not much evidence
  • Some studies have followed pts with conversion disorder and found that MANY years later they actually end up developing the real disease

Question 11

Conversion Disorder

Management

Answer 11

• Psychotherapy
• Relaxation
• Amytal interview
• Hypnosis

Question 12

Psychological Factors Affecting Other Medical Conditions

Answer 12

• A medical condition is present
• Psychological factors adversely affect the medical condition because:
  
  • They influence the course
  • They interfere with treatment
  • They constitute well established risk health risk
• Examples:
  
  • Anxiety exacerbating Asthma
  • Chronic occupational stress leading to HTN
  • Takotsubo cardiomyopathy - transient cardiac dysfunction, commonly triggered by physical or emotional stress
  • Migraine
  • IBS
  • Fibromyalgia

Question 13

Factitious Disorder

Answer 13

• Falsification of physical or psychological signs or symptoms, or induction of injury
• The individual presents to others as injured, ill or impaired
• The deceptive behavior is present even in the absence of rewards
• Behavior not explained by another mental disorder like a delusional disorder or psychosis

Question 14

Factitious Disorder Imposed on Another

Answer 14

(Previously Factitious Disorder by Proxy)

• Falsification of physical or psychological signs or symptoms, or induction of injury of another person
• Different from malingering
  
  • Malingering: tangible reward
  • Factitious Disorder: no reward

Question 15

Somatic Symptom Disorders

Comparison

Answer 15

• Malingering: tangible reward
• Factitious Disorder: no reward
• Conversion: unconscious process
• Illness Anxiety: absolutely believe they have sx w/ no or mild sx
• Somatic Symptom: absolutely believe they have sx, have sx

Question 16

Conclusions

Answer 16

• Psychosocial factors have been implicated Somatic Symptom Disorders
• It is important to recognize that the distress experienced by the patients is “real” and not “imagined”
• These conditions are more likely to be seen by PMD
• Establishment of good doctor patient relationship is therapeutic