Somatic Symptom Disorders (Tamburello) - 10/11/16

Question 1

Define “somatization.”

Answer 1

Individual’s behavior in response to physical symptoms (can be adaptive or maladaptive)

Question 2

Illness Behavior (2x2 table)

Answer 2

Question 3

Somatic Symptom Disorder

Diagnosis

Answer 3

• One or more somatic symptoms with:
  
  • Disproportionate/persistent thoughts re: seriousness
  • High level of anxiety about health/symptoms
  • Excessive time/energy devoted
• Symptoms > 6 months
• Specify if: with predominant pain

Question 4

Somatic Symptom Disorder

Theory

Answer 4

• Somatic amplification
  
  • Low threshold for unpleasant body sensations
  • Misinterpretation of body sensations (blown out of proportion)
• Alexithymia
  
  • Inability to accurately read one’s feelings
• Cultural expression of mood/anxiety

Question 5

Somatic Symptom Disorder

Risks

Answer 5

• Unnecessary tests → False positives
• Medications → Side effects
• Procedures/surgery → Complications

Question 6

Illness Anxiety Disorder

Answer 6

• Preoccupation/anxiety about illness
• Somatic symptoms not present or mild
• Excessive health-related behaviors or avoidance
• Fear symptoms > 6 months
• Specify if:
  
  • Care-seeking
  • Care-avoidant

Question 7

Conversion Disorder

Answer 7

• Neurologic symptoms or deficits that develop unconsciously and nonvolitionally
• Usually involve motor or sensory function
• Manifestations are incompatible with known pathophysiologic mechanisms or anatomic pathways.
• Hoover’s Sign - used to differentiate whether muscular weakness of is neurological origin
  
  • If the patient has weakness when you test extension of the right leg (A) but has detectable power in the right leg when you test flexion of the left leg (B) it implies that the patient is likely suffering from non-organic limb weakness (positive Hoover’s sign). In B the extension of the right leg occurs due to involuntary contraction of synergistic muscles.
• Often transient; may be associated w/ stress or trauma
• Usually no obvious external benefit (as expected in malingering)

Question 8

Factitious Disorder (aka Munchausen’s Syndrome)

Diagnosis

Answer 8

• Individual intentionally and falsely presents self as ill, impaired, or injured → goal: be in sick role
• Persists despite lack of “observious external rewards”
• Not psychotic
  
  • High morbidity and mortality from self-harm and medical complication

Question 9

Management of Somatic SYmptom Disorders

Answer 9

• Educate patient
  
  • Not “in their head”
  • Should be viewed as a unifying diagnosis not 17 things wrong but just 1)
• Have a strategy
  
  • Pick a quarterback (usually the PCP)
  • Regularly scheduled visits (they don’t need to have symptoms to come for follow-up)
  • Focused evaluation of new symptoms
• Address psychiatric comorbidities
  
  • Be cautious with medications (patients may be more sensitive to side effects of meds)
• Address internal and external reinforcers
  
  • Patients may become trapped by their somatization
  • Individual and group psychotherapy
  • Physical therapy
  • Occupational therapy/vocational rehab

Question 10

Malingering

Answer 10

• Intentional production of physical or mental health symptoms for purpose of maintaining secondary advantage
• May be somatic or psychological symptoms
• NOT a psychiatric disorder (but may be a focus of clinical concern)
• Common in antisocial personality disorder, legal situations

Question 11

Management of Malingering

Answer 11

• Confrontation with concern
  
  • Identify what individual wants or needs
  • Direct them to more adaptive methods of meeting their needs

Be careful! These are stigmatizing diagnoses - need evidence before coming to conclusion that your patient is feigning illness