Somatic Symptoms and related disorders Flashcards
Somatic symptoms and related disorders
- Kind of a miss-mash category (much better in DSM 5)
- Related to medical concerns but in somewhat different ways
Distress related to a bodily symptom
•bodily symptoms are purely descriptive (no clear cause)
•not concerned if there is a physical cause or not - the disorder is how upset the person is about ‘symptom’
•is any type of somatic symptom that causes persistent and significant distress, involving one or more of
1. Catastrophizing of seriousness of symptoms
2. Constant high anxiety about symptoms/general health
3. Excessive time/energy spent on symptoms/health concerns
Clinical picture is very diverse (variety of different symptoms) Somatization disorder (DSM 4 diagnosis) •many different vague physical symptoms across life with no medical explanation for most symptoms •lifelong distress and high use of health care system
Chronic pain/pain disorder (DSM 4 diagnosis)
•injury causes neuropathic pain: your injury never heals properly and nerves in that region become hyper sensitive
•exacerbated by distress about pain/disability, and avoidance related to pain exacerbates disability
•ex: in cancer remission, gets weird pain, thinks its cancer
Psychological factors
Cycle of catastrphization about symptoms
•excessive attention/worry to bodily symptoms
•attributing symptoms to illness
•help-seeking to treatment of symptoms
Similar to to panic disorder
•paying more attention to body = notice more sensation
Attentional bias towards illness related information
•conformation bias for symptoms/diseases
*look for information that confirms you’re really ill
•overestimate deadliness of diseases/underestimate ability to cope with diseases
Past experiences with illness
•can induce resilience or anxiety
•self, family, media depictions, experiences with health care systems (people feel like they’re not being heard so they go back or they get affirmation)
Emotional distress expressed as physical symptoms
•people in negative moods report more physical problems
•high absorption (tendency to get caught up in own experiences) - fantasy prone/hypnotisability
•high alexithymia (difficulty identifying emotions)
Focus on internal + low emotion awareness + negative mood/stress = lots of negative somatic experiences
*dont know about emotions, so focuses on body, and interprets low mood as bodily symptoms
Specific etiology if relevant
•ex:chronic pain - tissue is healed
Pain is a protective function so pain threshold must be more sensitive than injury threshold
•after injury, pain threshold gets more sensitive to protect body, BuT high sensitivity + negative attribution = catastophization cycle, leading to avoiding the situation entirely
Biological factors
•potentially immunosuppression by HPA axis
Prevalence and treatment
Unknown do to massive changes between DSMs
•estimate is 5-7%
•perhaps more likely in women because big differences in neurobiology of pain between sexes:
•may report pain differently because of social pressures (men reluctant to be vulnerable), neuroendocrine differences, but evidence that women are more resilient to pain than men for certain pains
Treatment
1. Psychoeducation about relavent medical circumstances
2. CBT for worry, anxiety, depression, help seeking behaviours, with graduated exposure to avoided activities
3. Manegement and restructuring of medical appoints
•regular but not on demand appointments
•treat all new symptoms as valid
•but avoid excessive medical tests and meds (don’t give in to their thinking)
Illness anxiety disorder
Preoccupied with fear of having/getting a serious illness with no somatic symptoms present (or very mild)
•exacerbated if risk exists (family history)
•excessive health related behaviours (checking body for lumps) or avoidance (avoid going to the doctor)
•persists for 6 months, but feared disease may change
Prevalence
•estimate from hypochondriasis from DSM 4 that 1 year is 1.3-10%
•same in sexes
Etiology
•similar to anxiety disorders and somatic symptoms disorder, with similar treatment as above
Conversion Disorder/Functional neurological symptom disorder
Functional: don’t know what neurological process is happening, but by observing their sensory/motor functioning we can infer they have a neurological disorder because theres no medical explanation
Disorder: abnormal sensory or motor function symptom with no medical explanation, with common symptoms including
1. Weakness/paralysis/abnormal movements (tremors, gait issues)
2. Problems swallowing
3. Speech symptoms (slurred speech,muteness)
4. Seizures, attacks (syncope/fainting attacks)
5. Anethesia, sensory loss (tingling, blindness), or sensory disturbance (double vision, tunnel vision)
One or more sensory motor symptom
Hallmark feature is symptom is not consistent with neurophysiology
•tremors going away when distracted •hoovers sign (pattern of movement in opposite limb in paralysis)
•glove anthesia: numbness in just one hand
Note: diagnosis makes no claim about how real the symptom is
•can’t prove the person is not feigning, but if this is proven, its not this diagnosis
Other features
•la belle indifference: person isn’t distressed about the disorder/symptoms (20% of patients)
•secondary gain = benefits from being unwell such as financial return, avoid responsibility
*can’t be aware of these gains or it isn’t this diagnosis
•primary gain: relief from conflict of underlying anxiety
*can’t be aware of this or usually not this diagnosis
Diagnosis: should be based on overall symptom picture, not just one finding
•important to rule out actual medical problems
•can’t be due to brain damage/other neurological conditions
•stressful life events may precipitate disorder
Psychological factors of conversion disorder
- Onset can be associated with stress/trauma
•soldiers in wartime
•lower levels of brain derived neurotrophic factor
•greater report of lifetime distressing events - Dissociation symptoms (during onset of symptoms or occurrence of attacks)
- Functioning often intact at implicit level
•unconscious functioning intact
•blind - but can navigate environment (especially in an emergency)
•symptoms removed following hypnosis/meds - Distress/psychological conflict repressed into unconscious then converted into physical symptom
•Socially acceptable way of expressing distress (more acceptable than strong negative emotions)
•more common in non western contexts, BUT not a choice made by patients (unconscious)
Biological factors of conversion disorder
- Stressful experiences
•HPA axis likely involvement
•brain derived neurotrophic factor in depression and conversion patients - Neuroimaging (small/limited samples)
•when asked to use symptomatic body region, less activation in regions related to that function, but greater activation in regions related to emotion regulation/expression
*orbitofrontal cortex, insula cortex (limbic system), amygdala, anterior cingulate
Case study: successful treatment of conversion muteness - decreased connectivity between speech regions and amygdala, more connectivity with anterior cingulate
Prevalence/treatment of conversion disorder
Temporary conversion symptoms are common (unknown prevalence)
•maybe 2-5%
•possible to have neurological condition and conversion disorder
Treatment (largely unknown)
1. Behavioural approach for motor symptoms
•graduated increase in relevant motor activity, rewards when show improvements
•do not reinforce impairment/collude with secondary gains
2. Psychodynamic approach: gain insight to underlying conflicts
•symptoms resolve once addressed
•symptoms usually disappear after hypnosis
3. Problem solving combined with above
Factitious Disorder/ “Munchausen syndrome”
Intentional (conscious) feeling of illness, injury, or impairment
•presents self to others this way
•requires positive evidence of feigning (seeing other person without symptom)
•absence of obvious external world (no obvious gain from feigning illness)
Various methods
•overstate severity, report non existent symptoms, behave injured, manipulate lab tests, ingest substances/injure self to induce symptoms
Factitious disorder imposed on another: feigning person in their care
•”factitious disorder by proxy”
•children most common
•abuse: often patient induces symptoms in the person
How to suspect this
1. Often due to unrealistic lab tests, repeated need for emergency care
2. Person with disorder reluctant to admit to behaviour
•appear to be devoted to child/other proxy
4. Many conflicting demands on medical care making diagnosis harder
5. If patient sense staff is suspicious, may go to different facility
6. Video taping interactions between proxy and abuser is helpful in diagnosis
Prevalence
•estimate of 1% in hospital settings
Malingering
Not a DSM5 disorder
Feigning for secondary gain
•money (lawsuit, insurance fraud)
•escape from responsibilities (work, exam)
