Somatic Symptom and Related Disorders

Question 1

Shared features of somatic symptom and related disorders?

Answer 1

1. Distressing somatic symptoms + abnormal thoughts, feelings, and behaviors in response to these symptoms
2. Commonly encountered in primary care and other medical settings and less so in mental health settings
3. Symptoms can be linked to medically explainable and unexplainable problems

Question 2

Factors contributing to somatic symptom and related disorders?

Answer 2

• Genetic and biological vulnerability (such as increased sensitivity to pain)
• Early traumatic experiences
• Learning (eg, attention from illness, no reinforcement of non-physical expressions of distress)
• Cultural/social norms that devalue/stigmatize psychological suffering as compared with physical suffering

Question 3

DSM-5 Criteria for Somatic Symptom Disorder?

Answer 3

A. 1+ somatic symptoms that are distressing or result in significant disruption of daily life
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least 1 of the following:
-Disproportionate and persistent thoughts about the seriousness of one’s symptoms
-Persistently high level of anxiety about health or symptoms
-Excessive time and energy devoted to these symptoms or health concerns
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)

Question 4

Specifiers for Somatic Symptom Disorder?

Answer 4

-With prominent pain (previously pain disorder)
-Persistent (severe symptoms, marked impairment, >6 months)
-Severity:
Mild (1-2 symptoms)
Moderate (2+ symptoms)
Severe (2+ symptoms + multiple somatic complains or one very severe complaint)

Question 5

Associated cognitive features that support Dx of Somatic Symptom Disorder?

Answer 5

Focus on somatic symptoms
Attribution of normal bodily sensations to physical illness
Concern about sickness
Fear of physical activity harming the body
Sensitization to pain

Question 6

Associated behavioral features that support Dx of Somatic Symptom Disorder?

Answer 6

Repeated bodily checking for abnormalities
Repeated seeking of medical help/reassurance
Associated with depressive disorders leading to increased suicide risk

Question 7

Prevalence of Somatic Symptom Disorder?

Answer 7

5-7%

Question 8

M vs. F - Somatic Symptom Disorder?

Answer 8

F>M

Question 9

Presentation of Somatic Symptom Disorder in children?

Answer 9

• Common symptoms: recurrent abdominal pain, headaches, fatigue, nausea
• More likely to have single symptom
• Not as much associated worry about illness prior to adolescence
• Parents’ reactions can determine level of distress

Question 10

Presentation of Somatic Symptom Disorder in older adults?

Answer 10

• Often underdiagnosed (physical symptoms of fatigue/pain thought to be normal part of aging, normalization of illness worry because of more general medical illnesses and medications than younger people)
• Depression is a common comorbidity

Question 11

Risk/prognostic factors of Somatic Symptom Disorder?

Answer 11

• Temperament (neuroticism is a risk factor), comorbid depression/anxiety
• Lower education level, lower SES, history of stressful life events
• Course modifiers: ongoing chronic illnesses, social stress, reinforcing social factors such as illness benefits

Question 12

Rx - Somatic Symptom Disorder

Answer 12

• PCP: identify one single primary caregiver, brief scheduled visits with no new work-up, referral
• Mental health provider: therapeutic alliance, reassurance, psychotherapy, role of medications

Question 13

DSM-5 Diagnostic Criteria - Illness Anxiety Disorder

Answer 13

A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are not present or are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate
C. High level of anxiety about health, easily alarmed about personal health status
D. Excessive health realted behaviors (repeatedly checking his or her body for signs of illness), maladaptive avoidance
E. Present for at least 6 months, but the specific illness that is feared may change over that period of time
F. Not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, GAD, BDD, OCD, or delusional disorder (somatic type)

Question 14

Specifiers for Illness Anxiety Disorder

Answer 14

Care-seeking type: medical care is frequently used

Care-avoidant type: medical care rarely used

Question 15

Features of Illness Anxiety Disorder?

Answer 15

• Comprehensive evaluation cannot attribute a serious medical condition to symptoms
• If medical condition exists, anxiety and preoccupation with condition are excessive and disproportionate
• Physical sign or symptom often normal physiological sensation, benign self-limited dysfunction, or a bodily discomfort not generally indicative of disease
• Found primarily in primary care setting
• Use a lot of medical resources

Question 16

Comorbidities of Illness Anxiety Disorder?

Answer 16

2/3 likely to have at least one, especially somatic symptom disorder and personality disorder

Question 17

Possible etiologies of Illness Anxiety Disorder?

Answer 17

• Cognitive - misinterpret bodily symptoms
• Learning model - sick role
• Psychodynamic - repression, displacement
• Variant - 80% have coexisting anxiety or depressive disorder

Question 18

Prevalence of Illness Anxiety Disorder?

Answer 18

1.3-10%

Question 19

M vs. F in Illness Anxiety Disorder?

Answer 19

M = F

Question 20

Onset of Illness Anxiety Disorder?

Answer 20

Early and middle adulthood

Question 21

Risk factors for Illness Anxiety Disorder?

Answer 21

Major life stress

History of childhood illness or abuse

Question 22

Course/prognosis of Illness Anxiety Disorder?

Answer 22

Tends to be chronic and relapsing

Up to 1/2 improve significantly

Question 23

Good prognostic indicators of Illness Anxiety Disorder?

Answer 23

• High SES
• Sudden onset
• Rx responsive depression/anxiety
• No personality disorder
• No medical condition

Question 24

Rx - Illness Anxiety Disorder?

Answer 24

• Emphasis on stress reduction and coping with chronic illness, group psychotherapy (insight oriented, CBT)
• Primary care - regularly scheduled visits, low frequency of investigations, logging of symptoms and concerns
• Pharmacotherapy - only responsive if treatment responsive underlying disorder

Question 25

DSM-5 Diagnostic Criteria - Conversion Disorder (aka Functional Neurological Symptom Disorder)

Answer 25

A. 1+ symptoms of altered voluntary motor or sensory function 2. Clinical findings provide evidence of incompatibility between the symptoms and recognized neurological or medical conditions C. Symptom or deficit not better explained by another medical or mental disorder D. Causes clinically significant distress/impairment, etc.

Question 26

Specifiers for Conversion Disorder?

Answer 26

Symptom type (weakness or paralysis, abnormal movements, swallowing symptoms, speech symptoms, attacks or seizures, anesthesia or sensory loss, special sensory symptom, mixed) - Acute (<6 months) or persistent (>6 months) - Psychological stressor or without psychological stressor

Question 27

Motor subtypes of conversion disorder?

Answer 27

- Tremors of limbs, head, or trunk (may increase with attention) - Impaired balance and coordination (astasia abasia) - Psychogenic paralysis (normal neuro exam)

Question 28

Sensory subtypes of conversion disorder?

Answer 28

- Loss of sensation of touch/pain (often midline) - Psychogenic blindness/deafness - Hallucinations

Question 29

Non-epileptic seizures/pseudoseizures?

Answer 29

- Often linked to a stressor, variable onset, increased frequency and longer in duration each time - Often occur in presence of others - Rarely bite tongue, incontinence, or associated injury - No postictal confusion - Maintaining pupillary and corneal reflexes - Concurrent EEG with no epileptiform activity and no post-seizure rise in Prl

Question 30

Examples of internal inconsistencies?

Answer 30

- Hoover's sign - Weakness of ankle plantar-flexion when supine but intact ability to walk on tip toes - Closed eyes with resistance to opening or a normal EEG (psychogenic seizures)

Question 31

History of patients with conversion disorder?

Answer 31

- Maladaptive personality traits - Possible hx of childhood abuse or neglect or stressful life events - Onset may be linked with stress or trauma - Often associated with dissociative symptoms (depersonalization, derealizaiton, dissociative amnesia)

Question 32

Lifetime prevalence of conversion disorder?

Answer 32

11-500/100,000

Question 33

M vs. F - conversion disorder?

Answer 33

2:1 F>M

Question 34

Onset of conversion disorder?

Answer 34

Adolescents and young adults, but can happen at anytime

Question 35

Conversion disorder more common in what populations?

Answer 35

``` Rural Less education Low IQ Low SES Combat exposure in military ```

Question 36

Possible etiologies of Conversion Disorder?

Answer 36

- Psychoanalytic (repression of unconscious intrapsychic conflict and the conversion of anxiety into a physical symptom) - Biologic - hypometabolism of dominant hemisphere and dysfucntional hypermetabolism of non-dominant hemisphere leading to impaired interhemispheric communication, increased cortical arousal leading to inhibition of awareness of bodily sensation - Significant history of abuse - Monozygotic > Dizygotic

Question 37

Features of conversion disorder?

Answer 37

- La belle indifference - lack of concern about nature or implications of symptoms - Identification (unconscious modeling)

Question 38

Rule of 1/3 - conversion disorder?

Answer 38

1.3 - re-diagnosed with a neurological problem 1/3 - maintain dx of pseudoseizure with a coexisting seizure disorder 1/3 - maintain diagnosis of pseudoseizure

Question 39

Course of conversion disorder?

Answer 39

Transient symptoms are common - Initial symptoms may resolve in first few days to 1 month - Remission in 2 weeks if stressor is addressed - 75% with no other episode - 25% with additional episode

Question 40

Good prognostic indicators of conversion disorder?

Answer 40

``` Sudden onset Identifiable stressor Good premorbid functioning No comorbidities No litigation Younger children > adults/adolescents ```

Question 41

Rx - conversion disorder

Answer 41

Usually spontaneous resolution -Alliance, avoid confrontation, decrease stressors, relaxation techniques, psychotherapy as needed, medication (anxiolytics may help)

Question 42

DSM-5 Criteria - Psychological Factors Affecting other Medical conditions?

Answer 42

A. Medical symptom or condition (other than a mental disorder) is present B. Psychological or or behavioral factors adversely affect the medical condition in one of the following ways: -Factors have influenced course of medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition -Factors interfere with treatment of the medical condition -Factors constitute additional well-established health risks -Factors influence underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention C. Psychological and behavioral factors are not better explained by another mental disorder ``` Can specify severity Mild - increases medical risk Moderate - aggravates medical condition Severe - results in hospitalization or ER visit Extreme - severe, life-threatening risk ```

Question 43

List some psychological or behavioral factors.

Answer 43

Psychological distress patterns of interpersonal interaction Coping styles Maladaptive health behaviors (denial of symptoms, poor adherence to medical recs)

Question 44

DSM-5 Diagnostic Criteria of Factitious Disorder imposed on self?

Answer 44

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception B. Individual presents himself/herself to others as ill, impaired, or injured C. Deceptive behavior evident even in the absence of obvious external rewards D. Behavior not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

Question 45

DSM-5 Diagnostic Criteria of Factitious Disorder imposed on another?

Answer 45

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception B. Individual presents another individual (victim) to others as ill, impaired, or injured C. Deceptive behavior evident even in the absence of obvious external rewards D. Behavior not better explained by another mental disorder, such as delusional disorder or another psychotic disorder Perpetrator receives this diagnosis (not the victim)

Question 46

Etiology of Factitious Disorder?

Answer 46

- Not well-understood - Case reports suggest history of childhood abuse/neglect -> inpatient hospitalizations -> nurturing escape from abusive home environment - Recreating a rejecting parent-child relationship with physicians - Masochistic personality (seek painful procedures)

Question 47

Rx - Factitious Disorder?

Answer 47

``` Management, not cure 3 major goals: -Reduce risk of morbidity and mortality -Address underlying mental health needs -Consider legal/ethical issues Foster good communication between medical/surgical provider and psychiatrist ```

Question 48

DSM-5 Criteria - Other Specified Somatic Symptom and Related Disorder?

Answer 48

Presentations in which symptoms characteristic of somatic symptom and related disorder that cause clinically significant distress or impairment predominate, but do not meet full criteria for any disorders

Question 49

Brief somatic symptom disorder?

Answer 49

Duration < 6 months

Question 50

Brief illness anxiety disorder

Answer 50

Duration < 6 months

Question 51

Illness anxiety disorder without excessive health-related behaviors?

Answer 51

Criterion D not met

Question 52

Pseudocyesis?

Answer 52

False belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy