somatic symptom disorders

Question 1

what are 3 common features of somatic disorders?

Answer 1

Presenting problem is somatic in nature; medical illness must be ruled out

Physical findings are either lacking, or out of proportion to the level of subjective distress

Common occurrence in primary care

Question 2

what are the 5 Somatic Symptom and Related Disorders (formerly “Somatoform Disorders”):

Answer 2

1. Somatic Symptom Disorder
2. Illness Anxiety Disorder (formerly called Hypochondriasis)
3. Conversion Disorder (Functional Neurological Symptom disorder)
4. Psychological Factors affecting Other Medical Conditions
5. Factitious Disorder

Question 3

what are the 6 OCD disorders (HOT BED)

Answer 3

Obsessive-Compulsive Disorder (OCD)
Body Dysmorphic Disorder
Hoarding Disorder
Trichotillomania (Hair-Pulling Disorder)
Excoriation (Skin-Picking) Disorder
Body-focused repetitive behavior that causes significant impairment or distress (e.g. nail biting, lip chewing

Question 4

t/f:

Note: OCD sx can also be due to substance abuse/withdrawal, prescribed medications, and other medical disorders (e.g. anorexia nervosa and schizophrenia)

Answer 4

true

Question 5

(Panic DO) involve somatic symptoms, lead to search for medical care, but the symptoms follow a classic pattern

Answer 5

adult anxiety disorder

Question 6

involve unusual preoccupation with a wide variety of somatic symptoms

Answer 6

somatic symtpom disorder

Question 7

are often associated with somatic distress; may require modification of approach (“trauma informed care”)

Answer 7

trauma informed care

Question 8

seen in plastic surgery, general practice and dermatology

Answer 8

OCD disorder

Question 9

May start early in life
Affects mostly women
Multiple and shifting somatic symptoms, often dramatically described
Chaotic life circumstances and abuse history are common
Medically unexplained or only marginally explained complaints
Comorbid depression is common; often missed

describes what?

Answer 9

somatic symptom disorder

Question 10

what is prevalence fo somatic symptom disorder?

wehre is it more commn?

what is it related to?

Answer 10

5-7% of the general population
More common in rural areas and less educated patients
Often related to recent stress, history of physical abuse, and/or sexual molestation
Alexithymia

Question 11

what is alexithymia?

Answer 11

Inability to express feelings in words. Many patients with “unfounded” somatic complaints are unable to express emotional hurt, fear, anger, etc. in words,

Question 12

what are the 7 most common somatization symptoms in descending order?

Answer 12

Nervousness
Back Pain
Weakness
Joint Pain
Dizziness
Extremity Pain
Fatigue

Question 13

all sympotms of ______

Nausea
Headache
Dyspnea
Chest Pain
Abdominal Bloating
Constipation

Answer 13

somatization symptoms

Question 14

when should somatization disorder be in DDX?

4 situations

Answer 14

All of these symptoms can have “real” medical causes, but somatization disorder should be included in the differential diagnosis, especially if the patient has a history of vague and shifting complaints, lack of physical findings, a thick chart, and a chaotic and stressful life.

Question 15

describes what?

Can involve any of the organ systems
Urgent and compelling presentation
Alexithymia (inability to express feelings in words, genuinely unaware of emotional and stressful issues, or their impact)
Often result in unnecessary or unhelpful prescriptions and operations

Answer 15

somatic symptom disorder

Question 16

all in the ddx for what?

Anxiety (Panic) Disorder; e.g. chest pains
Major Depression (Sig-e-caps)
Conversion Disorder (neurological sx)
Schizophrenia (somatic delusions)
Malingering (lying about symptoms)
Unrecognized medical problem (e.g. multiple sclerosis, cancer)
Chronic stress

Answer 16

somatic symtom disorder

Question 17

pain threshold in somatic symtom disorder?

Answer 17

low

Question 18

Preoccupation with having or acquiring a serious illness, often in the absence of symptoms, or with minimal symptoms. One preoccupation at a time, such as HIV, cancer). Lasts for 6 months or more; cannot be reassured.
Primary concern is the idea of being ill.
If symptoms are present, the preoccupation is clearly excessive.

Answer 18

Illness Anxiety Disorder (Hypochondriasis)

Question 19

Symptoms typically look neurological (paralyses, seizures, tunnel vision, numbness)
Sx do not follow known neural pathways
Not consciously feigned
Causes significant distress or impairment
Often starts under overwhelming stress (funerals, family arguments, etc.)
Approx. 5% of referrals to neurology clinics

Answer 19

conversion disorder

Question 20

what is the most significant symptom of conversion disorder?

Answer 20

Sx DO NOT follow known neural pathways

Question 21

First recognized in 19th Century
Disorder which gave rise to the development of psychoanalysis
Psychological problems are being “converted” into medical complaints
Pseudo-seizures and unexplained paralyses are common

Answer 21

conversion disorder

Question 22

5 ways to tx somatic symtoms disorders?

Answer 22

First do no harm….Avoid invasive procedures if possible
Good news-bad news approach:
“The good news is you don’t have a serious disease. The bad news is that this seems to be your body’s way of dealing with stress. That’s what we need to talk about.”
Hypnosis (pts. tend to be suggestible)
Family counseling
Cognitive Behavior Therapy (reinforce healthy behavior and more effective problem solving)
Physical Therapy

Question 23

Any medical illness is affected by psychological factors.

Anxiety, tragedy, life stress, abuse, and chaotic circumstances affect development, course, and exacerbation of illness.

describes what?

Answer 23

pscyhological factors afffecting other medical conditions

Question 24

Patient feigns medical or psychiatric illness, with primary goal of getting admitted (or having child admitted) to hospital.
Examples: purposely-inflicted infections, faked lab findings (hematuria), claims of mental problems arising from “trauma” that never happened.
Behavior occurs in the absence of an external reward or gain. Key concept: Patient engages in willful deception.

Answer 24

Factitious Disorder

Question 25

If a person imposes feigned illness on another (child, pet, elderly patient), the perpretrator is given this diagnosis. The victim may be given an “abuse” diagnosis.

Answer 25

Factitious Disorder Imposed on Another(Muenchhausen’s by Proxy)

Question 26

_ In this case, the patient also feigns illness, but the potential rewards are obvious: Insurance money, time off from work, discharge from jail into hospital care, etc._

Answer 26

malingering

Question 27

These are actually not considered “somatic symptom disorders,” but also involve specific medical (cognitive) symptoms, related to overwhelming anxiety states. They are mentioned in this context because they may look “neurological,” and deserve a thorough workup.

Answer 27

Dissociative Disorders(Amnestic States)

Question 28

Sudden amnesia, often related to traumatic experiences.

Answer 28

Dissociative amnesia:

Question 29

Sudden unexpected travel with inability to recall one’s past. Often the patient does not know his own identity

Answer 29

Dissociative Fugue:

Question 30

Feeling like one is “on the outside looking in”

Answer 30

Depersonalization Disorder

Question 31

Assuming one of several “identities” or “alters” when stressed. Usually related to childhood trauma. Controversial diagnosis.

Answer 31

Dissociative Identity Disorder (Multiple Personality

Question 32

Formerly classified as an anxiety disorder.

Somatic concerns may predominate, as in Body Dysmorphic Disorder.

Answer 32

OCD

Question 33

what are the 4 amnestic states?

Answer 33

Dissociative amnesia:
Sudden amnesia, often related to traumatic experiences.
Dissociative Fugue:
Sudden unexpected travel with inability to recall one’s past. Often the patient does not know his own identity
Depersonalization Disorder
Feeling like one is “on the outside looking in”
Dissociative Identity Disorder (Multiple Personality)
Assuming one of several “identities” or “alters” when stressed. Usually related to childhood trauma. Controversial diagnosis.

Question 34

Recurrent, persistent, intrusive thoughts, impulses, or images
Not simply excessive worries about real-life problems
Patient cannot ignore or suppress such thoughts, impulses, or images
Patient recognizes that the thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion), but feels compelled to act on them.

Answer 34

obsessions

Question 35

defines what: unshakeable false beliefs, firmly held

Answer 35

delusions

Question 36

what are obesssios?

Answer 36

intrusive thoughts that the patient perceives as unwanted.

Question 37

Checking
Washing
Counting
Confessing
Symmetry/precision
Hoarding
>50% have more than one

are all______

Answer 37

compulsions

Question 38

Characterized by preoccupation (obsession) with imagined defects of face and body, and the compulsion to do something about it. These patients are
Frequent clients of plastic surgeons
Consumers of “recreational surgery” (nose jobs, tummy tucks, breast surgery, face lifts, botox and silicone injections
Usually dissatisfied with the results; often start law suits

Answer 38

Body Dysmorphic Disorder

Question 39

Massage (deep tissue and myofascial release) for pain
Acupuncture (“medical acupuncture”) for pain and nausea
T’ai Chi (improves mood, balance, and flexibility)
Some forms of Yoga (Careful! Easy to over-do!)
Biofeedback and Relaxation Training for anxiety
Mindfulness Training for general outlook
Stress Management for setting limits
Psychotherapy (CBT) for depression and anxiety
Meditation and Prayer for calmness
Dietary and lifestyle changes for general well-being

Answer 39

Evidence-based Complementary and Alternative Approaches that should be considered:

Question 40

First, do no harm. Encourage healthy living.
Take a good psycho-social history. Know the patient as a person. Screen for depression and anxiety states.
Consider these disorders in your differential diagnosis from the beginning, not only after negative test results
Do not get trapped into mind-body dualism (“real pain” or “psychiatric problem”)
Support, boundaries, calm reassurance, regular visits.
Refer for adjunctive treatments, such as massage, support group, T’ai Chi, Biofeedback
Referral for psychotherapy and/or medication for depression and anxiety.

Answer 40

tx of somatic symptom disorder

Question 41

Physical complaints and pain can be a primary psychiatric problem, a physical problem, or – most often - a combination of both

Answer 41

take home