somatic symptom disorders Flashcards
what are 3 common features of somatic disorders?
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
what are the 5 Somatic Symptom and Related Disorders (formerly “Somatoform Disorders”):
- Somatic Symptom Disorder
- Illness Anxiety Disorder (formerly called Hypochondriasis)
- Conversion Disorder (Functional Neurological Symptom disorder)
- Psychological Factors affecting Other Medical Conditions
- Factitious Disorder
what are the 6 OCD disorders (HOT BED)
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
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)
true
(Panic DO) involve somatic symptoms, lead to search for medical care, but the symptoms follow a classic pattern
adult anxiety disorder
involve unusual preoccupation with a wide variety of somatic symptoms
somatic symtpom disorder
are often associated with somatic distress; may require modification of approach (“trauma informed care”)
trauma informed care
seen in plastic surgery, general practice and dermatology
OCD disorder
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?
somatic symptom disorder
what is prevalence fo somatic symptom disorder?
wehre is it more commn?
what is it related to?
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
what is alexithymia?
Inability to express feelings in words. Many patients with “unfounded” somatic complaints are unable to express emotional hurt, fear, anger, etc. in words,
what are the 7 most common somatization symptoms in descending order?
Nervousness
Back Pain
Weakness
Joint Pain
Dizziness
Extremity Pain
Fatigue
all sympotms of ______
Nausea
Headache
Dyspnea
Chest Pain
Abdominal Bloating
Constipation
somatization symptoms
when should somatization disorder be in DDX?
4 situations
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.
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
somatic symptom disorder
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
somatic symtom disorder
pain threshold in somatic symtom disorder?
low
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.
Illness Anxiety Disorder (Hypochondriasis)
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
conversion disorder
what is the most significant symptom of conversion disorder?
Sx DO NOT follow known neural pathways
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
conversion disorder
5 ways to tx somatic symtoms disorders?
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
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?
pscyhological factors afffecting other medical conditions
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.
Factitious Disorder
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.
Factitious Disorder Imposed on Another(Muenchhausen’s by Proxy)
_ 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._
malingering
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.
Dissociative Disorders(Amnestic States)
Sudden amnesia, often related to traumatic experiences.
Dissociative amnesia:
Sudden unexpected travel with inability to recall one’s past. Often the patient does not know his own identity
Dissociative Fugue:
Feeling like one is “on the outside looking in”
Depersonalization Disorder
Assuming one of several “identities” or “alters” when stressed. Usually related to childhood trauma. Controversial diagnosis.
Dissociative Identity Disorder (Multiple Personality
Formerly classified as an anxiety disorder.
Somatic concerns may predominate, as in Body Dysmorphic Disorder.
OCD
what are the 4 amnestic states?
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.
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.
obsessions
defines what: unshakeable false beliefs, firmly held
delusions
what are obesssios?
intrusive thoughts that the patient perceives as unwanted.
Checking
Washing
Counting
Confessing
Symmetry/precision
Hoarding
>50% have more than one
are all______
compulsions
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
Body Dysmorphic Disorder
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
Evidence-based Complementary and Alternative Approaches that should be considered:
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.
tx of somatic symptom disorder
Physical complaints and pain can be a primary psychiatric problem, a physical problem, or – most often - a combination of both
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