Somatic Symptom and Related Disorders Flashcards
What are the four somatic diagnoses when the patient will unconsciously produce their symptoms?
- Somatic symptom - preoccupation with symptoms
- Illness anxiety - preoccupation with disease
- Conversion - symptoms appear neurologic
- Pseudocyesis - thinks she is pregnant when not
What are the two somatic diagnoses when the patient is consciously producing symptoms (lying)?
- Factitious disorder - patient wants to play the sick role
2. Malingering - patient wants to get something (i.e. drugs, time off work)
What are some developmental factors which may cause someone to develop a somatic symptoms disorder later in life?
- Patient’s mother has increased worries regarding health issues / catastrophic worries about illness
- Patient may have gotten attention from parents by using physical complaints
- Chronic parental illness
What home environment might promote somatization?
If psychiatric disorders are stigmatized (as is the case with the memo), somatization may be more successful
How should you treat a patient who you expect has a somatization disorder?
Take a complete and careful history + physical exam, be empathetic and ensure that their symptoms are taken seriously, do NOT be confrontational, try to interpret the connection between their physical / psych symptoms, help them explore factors which alleviate their symptoms (give them control)
Key: Ensure regular follow-up with PCP and Psychiatrist to decrease repeated, useless tests
What are the criteria for Somatic Symptom Disorder?
A. 1 or more somatic symptoms
B. Thoughts / feelings / behaviors about SYMPTOMS disproportionate and persistent with regards to seriousness. High levels of anxiety / energy devoted to illness.
C. Duration of any symptoms >6 months
What makes a somatic symptom disorder mild, moderate, or severe?
Mild - Only one symptoms of criterion B
Moderate - 2+ symptoms from B
Severe - 2+ symptoms from B AND multiple somatic complaints, or a very severe one.
What clinical features suggest a somatization disorder?
Normal lab tests, with multiple organ system involvement, but early onset & chronic course without any physical signs
What is an important subset of somatic symptom disorder?
Somatic symptom disorder with predominant pain
How will patients present with Somatic symptom disorder with predominant pain?
A long history of medical / surgical care, insisting that life would be great without the pain (rose-tinted glasses), complicated by substance use disorders / MDD typically
What are the criteria for Illness Anxiety Disorder?
A. Preoccupation with having or getting a serious illness
B. Somatic symptoms will be mild or not present
C. High level of anxiety about health
D. Excessive health-related behaviors / maladaptive avoidance
E. Pattern of behavior present at least 6 months
Are patients with Illness Anxiety Disorder delusional?
No, they are able to consider that the disease is not present -> it is not a fixed, false delief
What is Functional Neurological Symptom Disorder?
Also known as Conversion Disorder
-> patients present with symptoms which appear neurological but without a medical cause
i.e. “Functional Amblyopia”
What are the criteria for Conversion Disorder?
A. 1+ Symptoms of altered voluntary motor / sensory function
B. Physical findings are not compatible with known neurological syndromes
C. Symptoms are not intentionally produced
-> generally more acute, transient symptoms
What are some common conversion disorder symptoms?
Paralysis, blindness, mutism, pseudoseizures
What typically precedes the development of a conversion disorder?
A precipitating conflict or stressor -> i.e. they saw a horrible mass shooting so they go physically blind
What is “La belle indifference”?
A symptom associated with conversion disorder, whereby the patient is inappropriately cavalier given how serious their conversion symptoms are.
“Aww im blind now, nbd it happens”
What are the criteria for Pseudocyesis?
False belief of being pregnant which is nondelusional and actually associated with objective signs, including abdominal enlargement, reduced menstrual flow / amenorrhea, feeling fetal movement, nausea, breast engorgement / secretions, and labor pains at expected delivery date
How are somatic symptoms in a mood or anxiety disorder differentiated from a somatic symptom disorder?
During a mood or anxiety disorder, somatic concerns occur only during the mood or anxiety episodes
What is one common medical condition which is often misdiagnosed as a Conversion Disorder?
Multiple sclerosis (25-50% of cases)
What are the common comorbid conditions with somatic symptoms disorders?
Anxiety, depression, substance abuse, personality disorders
What is one thing a doc must watch about themselves when they’re treating someone with a somatic symptoms disorder?
Recognize their countertransference -> do not want to dread that interaction and let it show
What does a good psychiatrist recommend to a PCP regarding somatic symptoms disorder in future visits?
Discuss the chronic course, low morbidity / mortality
Recommend regular appointments with a focus physical exam based on their complaints
-> reduce healthcare costs
Keep medications and procedures to a minimum unless there’s a clear indication
How do you explain a somatic symptom disorder to a patient?
Explain symptoms are not caused by a serious disease, refrain from confrontation
What types of therapies are good for somatic symptom disorders and why?
CBT, psychoeducation, insight-oriented therapy
Family therapy -> when somatization is used for communication to family
Group therapy -> when used to establish / maintain relationships
What is the conversion therapy treatment?
Physical therapy
Exercise -> gradually escalating program
“Suggestion of cure” - tell them you’ve seen this get better before
Relaxation / meditation
When are drugs used in somatic / related disorders?
Only really to treat comorbid conditions
How does Factitious disorder differ from Malingering?
Fictitious disorder -> patient wants to assume the sick role, and external incentives are missing.
Malingering -> external incentives are the point
What is it called when your factitious disorder is predominantly physical symptoms?
Munchausen Syndrome
Who is typically affected with Factitious disorder?
Males who are familiar with medical issues.
Are patients with Factitious disorder willing to be treated? How will you know they’re lying?
Yes -> they will undergo multiple procedures and tamper with test data
You will know they’re lying when their condition defies conventional understanding, not responding to usual treatment, and they can predict the course (they are making it up)
How should factitious disorder be treated?
Remember that they are MENTALLY ILL
- > do not confront, be empathetic
- > refer to PCP as a gatekeeper
- > avoid unnecessary tests and procedures (basically just ignore it)
- > treat underlying mood / anxiety conditions
- > monitor your countertransference
What is Factitious Disorder by Proxy? How should this be managed?
Caregiver purposely causing harm to someone (typically a child) under their care to gain attention of medical staff / others
- > a very lethal form of abuse
- > contact Child Protective Services
What are the three usual external motivations of Malingering?
- Avoidance of difficult / dangerous situation, responsibilities, or punishment
- Receive compensation, hospital stay, or drugs
- Retaliation from job or financial loss
When will symptoms stop in Malingering?
When they or no longer profitable or when risk is too great
-> patient tampers with test data and may have self-inflicted illness
What personality disorder is closely associated with malingering? How can you tell its probably this?
Antisocial personality disorder
-> most likely patient will not be compliant with diagnosis and treatment
How should you manage malingering?
Do not confront the patient, maintain a relationship with them so you can carefully observe and document the inconsistency of their symptoms, provide a mechanism to allow them to “Save face” when the shit hits the fan
