Somatic Symptom and Dissociative Disorders

Question 1

What are somatic symptom disorders characterized by?

Answer 1

Disorders where the person has distressing somatic [bodily] symptoms with abnormal thoughts, feelings and/or behaviors in response to somatic symptoms

Question 2

What are the 4 somatic symptom disorders and 1 related disorder?

Answer 2

1. somatic symptom disorder
2. illness anxiety disorder [hypochondriac]
3. conversion disorder
4. psychological factors affect other medical conditions

Related: factitious disorder

Question 3

What are the 3 characteristics that define somatic symptom disorder?

Answer 3

The patient will have at least ONE somatic symptom that is distressing and causes significant disruption of life.
They have at least 1 of the following:
1. disproportionate/persistant thoughts about the seriousness
2. persistently high anxiety
3. excessive time and energy devoted to the symptom/health concerns

typically, they will have multiple somatic concerns [usually pain]

Question 4

What percent of the population is thought to have somatic symptom disorder?
Do more men or women have it?
What is the course of the disorder?

Answer 4

5% of the population with a female predominance

The course is chronic and significant disability may occur

Question 5

Describe the multifactorial approach to treatment of somatic symptom disorder.

Answer 5

1. regularly scheduled visits with 1 primary care provider who learns the typical symptoms and can minimize repeat testing/procedures [new vs. repeat].
   - regular followup is so the patient doesn’t have to “develop new symptoms” to be seen by the doctors
2. focused PE at each visit to “lay hands on patient”
3. ask about psychosocial situations/stressors
   - elicit patterns of exacerbation/stress
   - with rapport/trust, the patient may make the connections, but if pushed too quick, will change docs
4. empathetic and supportive
5. manage symptoms, NOT necessarily resolution
   - new symptoms will appear, old will disappear
   - patient just wants compassion/understanding
6. psych referral ONLY once rapport has been est. and should be for:
   - collaboration with the PCP not transferring the patient
   - helping the patient cope with chronic pain/illness

Question 6

When should a patient with somatic symptom disorder be referred to a psychiatrist?
What should the referral be for?

Answer 6

Once rapport has been established btwn the patient and PCP.
Referral should be for:
1. collaboration with PCP, not transferring patient care
2. in terms of helping the patient cope with chronic illness and disabling symptoms

Question 7

If a patient has somatic symptom disorder, and the primary complaint is pain, what is it important to educate the patient about?
What multidisciplinary team would be best at treating this patient?

Answer 7

the mind-body duality of pain

1. PCP with strong pain management skills or in collaboration with a pain specialist
   - focus on managing pain through the use of non invasive, non-narcotic treatments like dual agent anti depressants [5HT, NE–>TCAs, SNRIs]
2. rehabilitation doc, PT, OT
   - highest level of functioning despite pain
3. psychotherapist
   - focus on psychological aspects of pain by using biofeedback, hypnosis

Question 8

A patient presents with paralysis, blindness, mutism, seizures, hemianesthesia, or ataxia that is not consistent or compatable with a neurological or medical condition. What is this called?
What sex is it more common in?
What is it most frequently associated with?

Answer 8

Conversion disorder/functional neurological symptoms disorder where the patient manifests motor/sensory symptoms incompatible with neurological or medical conditions

Question 9

What are some common PE findings in patients with conversion disorder?

Answer 9

1. Hoover’s sign- the patient lies face up with legs straight and the physician can feel the “paralyzed” leg push down into the table as the patient lifts the non-paralyzed leg
2. weak plantar flexion in a patient that can walk on their toes
3. tremor changes when the patient gets distracted
4. resisted eyelid lifting during “seizure”
5. vision loss with “tunnel vision”

Question 10

What is “la belle indifference”?

Answer 10

When a patient with conversion disorder seems indifferent in the face of physical symptoms that would normally elicit distress or dispair

Question 11

What is somatization?
Is it always pathological?
Is it conscious or intentional?
What factors influence the development of this behavior?

Answer 11

psychological distress manifesting as physical symptoms.
It is not always pathological and can manifest for example as a stomach ache before a large exam, or stress headaches.
There is mind-body disconnect where the brain senses or creates a physical problem

Not conscious or intentional!!

Modeling or conditioning influence somatization. Ex.

1. demanding parents get nurturing when ill
2. seriously ill family member in the house

Question 12

With somatization, how long do symptoms tend to last?

What is the recurrence and when do recurrences tend to occur?

Answer 12

The symptoms generally resolve in days- wks.

Recurrence occur in 25% and usually manifests in times of stress

Question 13

What is the treatment of conversion disorder?

Answer 13

1. avoid saying
   - you don’t have anything
   - the tests say nothings wrong
   - you need a psychiatrist
   - you don’t have anything I can treat
2. say
   - the good news is it appears you don’t have epilepsy, but clearly you have something going on, so what can we do to help you?
3. involve PMR and psych to help the patient cope with symptoms

Question 14

Bob has preoccupation with getting cancer but he has no significant somatic symptoms. He is very anxious about his health status and is constantly looking for signs of illness and researching signs of cancer.
What somatic disorder does he have? What percent of patients in the primary care setting have it?
What is the gender preference?
What is the prognosis?
What is treatment?

Answer 14

Illness Anxiety disorder [hypochondriasis]
5-10% and equally common in males/females
Will resolve in months/years but can exacerbate in times of stress.
Treatment:
1. regularly scheduled visits with a PCP
2. avoid saying there is nothing wrong with the person, or that its all in their head, etc
3. psychotherapy referral, but usually patient refuses

Question 15

What are the 4 ways psychological/behavior factors can adversely affect a medical condition?

Answer 15

1. close temporal relationship btwn psych factors and development, exacerbation, delayed improvement of a medical condition
2. factors interfere with treatment [non-adherence]
3. additional health risks
4. affect physiology of the medical condition

Ex. psychological distress, problematic interpersonal interactions, maladaptive coping and health behaviors

Question 16

What is facticious disorder?

How does it differ from malingering?

Answer 16

Symptoms or evidence of disease are intentionally-induced/produced by a person.
It differs from malingering because there is no evidence of obvious EXTERNAL rewards.

Ex. 
Produced:
1. blood in urine to mimic serious kidney disease
2. heating thermometer
Induced:
1. bleeding oneself to make anemia
2. injecting unsterile material --> sepsis
3. injecting insulin-> hypoglycemia

Question 17

What is thought to be the motive behind facticious disorder?

Answer 17

The patient wants the “privilege of the sick role” where they get nurtured.

1. sanctioned dependency- allowed to regress and depend on others
2. attention and sympathy

Question 18

What is Munchausen syndrome and facticious disorder by proxy?

Answer 18

Munchausen= person lives to be a patient

Facticious by proxy is diagnosed when a person [usually mother] intentionally produces/induces symptoms in the child for the privileges of the sick role

Question 19

How is diagnosis of facticious disorder and FD by proxy made?

Answer 19

1. video surveillance

2. 1 to 1 sitter to demonstrate that the disorder resolves w/ direct supervision

Question 20

What is malingering?

Answer 20

It is NOT a psychiatric disorder, but it is similar to facticious disorder. The person intentionally induces or produces symptoms for personal benefit and external reward such as:

• financial assistance/disability
• avoid legal charges/jail
• food and shelter
• avoid military duty
• obtain drugs

Question 21

A person drives for many mile but cannot remember landmarks or towns they have passed. What kind of dissociation is this?

Answer 21

normal

Question 22

What are dissociative disorders?

Answer 22

dissociation is when certain behavioral/mental processes from ones subjective sense of reality are partitioned off.

A disorder of this is when a person blocks mental/behavioral processes in order to avoid or escape overwhelming situations

Question 23

A patient presents with the inability to recall personal information about himself after a traumatic event. He can learn new information and remember general information. He is otherwise cognitively and neurologically normal.
What is this called?

Answer 23

Dissociative amnesia

Question 24

What is dissociative identity disorder?

What is it almost always associated with?

Answer 24

a person has 2 or more identities/personalities/alters.
The person is amnestic for the existence and behavior of the alters.

It is almost always associated with childhood physical/sexual abuse

Question 25

What is depersonalization disorder?

Answer 25

The person has persistent and recurrent feelings that they are detached from their own mental and physical being.

Question 26

What is derealization disorder?

Answer 26

A person feels that the surroundings are unreal and they are detached from them