Somatic Symptom Disorders

Question 1

Conversion Disorder

Answer 1

• Unexplained symptoms of voluntary motor or sensory function —> distress and functional decline
• Typical presentations = Sudden blindness, inability to move body part, loss of sensation in limb (may not be exact dermatome though), swallowing problems, non-epileptic sz (eyes closed, may respond to commands)
• Usually self-limited w/in 2 wks and 50% symptom free at 1 yr
• Good prognosis if … early tx, acute onset, intelligence, no co-morbidity, good social environment
• Onset 10-35 yo
• Female&raquo_space; male
• Esp in low SES and rural areas
• 2/3 have trauma hx

Question 2

Illness Anxiety Disorder

Answer 2

• Intense anxiety about poss undiagnosed illness
• Epidemiology
  
  • More males
  • Nearly 10% of those at PCP
• Clinical = Heightened body sensation, frequent trips to PCP, significant distress and time spent on it, not easily reassured

Question 3

Somatic Symptom Disorder

Answer 3

• Chronic somatic symptoms (not focused on specific illness)
• Only need to have 1 symptom to have diagnosis; may have actual physical cause but if excessive worry then still make diagnosis
• Epidemiology
  
  • More females
  • .1-2% prevalence but up to 14% in primary care
  • Early onset (adolescence)
  • Chronic
  • Poor prognosis (usually still symptomatic 8 yrs later)
  • Associated w/ low SES, hx child sexual abuse, rural
  • Family hx of males w/ alcohol problems or antisocial personality OR hx females w/ somatization
  • Often co-morbid w/ histrionic personality disorder
• Clinical = Excessively fearful, concerned; frequent doc visits; distress
  
  • Often overlap w/ food allergies, atypical chest pain, tinnitus, TMG, IBS, chronic fatigue syndrome, fibromyalgia, PMS, systemic candidiasis, migraines

Question 4

Possible Causes

Answer 4

• Amplification of bodily sensations
  
  • Negative misinterpretation of physical sensations
• Need for sick role
  
  • Pt has family or culture that do not accept failure but do accept illness
  • When cannot meet expectations they deny it —> physical symptoms
• Bio
  
  • Genetic rlel
  • fMRI - central inhibition and limbic abnormalities (not diagnostic)
• Psycho
  
  • Unconscious psych conflict
  • Social learning
• Social
  
  • Cultural and gender differences

Question 5

Management

Answer 5

• Tips
  
  • Be caring
  • Avoid long work ups and procedures
  • Provide acceptable explanation and set goals
  • Brief but regular office visits that do not require a new symptom to have occurred
  • SSRIs for associated anxiety and depression
  • Exercise + other stress reduction (alternative medicine)
  • Psychoeducation and psychotherapy
  • Benign interventions - cold pads, bandages, vitamins
• What to say…
  
  • Summarize signs/symptoms
  • Good news (nothing seriously wrong)
  • Bad news (we do not know exactly why)
  • Suggest psychiatrist
  • Assure them they are not crazy and tell them they have the power to get better (power of suggestion)

Question 6

Somatic Symptom v. Factitious v. Malingering

Answer 6

Somatic Symptom - Unconscious Mechanism/ Unconscious Motivation
-Do not know that symptoms are made up

Factitious - Conscious Mechanism/Unconscious Motivation
-Do not know why they make up symptoms

Malingering - Conscious Mechanism/Conscious Motivation
-Ex) make up symptoms to have place to stay in hospital

Question 7

Primary v Secondary Gain

Answer 7

Primary Gain = internal; lowers awareness of anxiety about a problem

Secondary Gain = external; lowers responsibility and garners care and support from others