somatoform disorder

Question 1

what are the 7 types of somatoform disorders?

Answer 1

1. somatization disorder (now somatic symptom disorder)
2. conversion disorder
3. hypochondriasis (only in DSM4, removed in 5)
4. body dysmorphic disorder (BDD)
5. pain disorder (DSM4 only, removed in 5)
6. factitious disorder
7. malingering

Question 2

what are some of the general characteristics of somatoform disorders?

Answer 2

involve both unconscious and social factors that may result that may result in primary or secondary gain

Question 3

overview of somatoform disorder?

Answer 3

1. At least 30% of physical complaints of primary care patients cannot be explained by organic illness or substance abuse
2. Some examples include headaches, nausea, menstrual irregularities, and paresthesias.
3. Such complaints tend to involve both social and psychological factors

Question 4

Somatization Disorder (Somatic Symptom DisorderDSM5)

Answer 4

≥4 pain issues
2 gastrointestinal,
1 sexual,
1 neurological symptom
None can adequately be explained by medical causes after history, examination, labs, tests
Onset before age 30
Symptoms tend to be chronic and complete remission is rare
* Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Question 5

unconscious motivaiton is

Answer 5

factitious disorder

Question 6

conscious motivation is

Answer 6

malingering

Question 7

General characteristics of somatoform dz

Answer 7

Involve both unconscious (patient is unaware of the behaviors or symptoms, does not control them) and social factors that may result in primary or secondary gain
Primary gain: internal/psychic motivations
Secondary gain: external motivations (need housing, disability, drugs, need to be cared for)
Increased incidence in women (equal in hypochondriasis)
Tend to start in early adulthood and worsen with stress
50% have a co-morbid mental illness – anxiety, depression
Cause impairment in social and/or occupational function

Question 8

etiology of somatoform dz

Answer 8

Somatization disorder, hypochondriasis, and pain disorder tend to run in families
– increased incidence in monozygotic vs. dizygotic twins
Increased incidence of hypochondriasis and pain disorder with a family history of mood disorder or obsessive-compulsive disorder (OCD)
Increased incidence of somatization disorder with a family history of antisocial personality disorder or alcoholism
Literature suggests that serotonin-related gene pathways may be involved (specifically serotonergic hypofunction)

Question 9

Somatization Disorder (Somatic Symptom DisorderDSM5)

Answer 9

≥4 pain issues
2 gastrointestinal,
1 sexual,
1 neurological symptom
None can adequately be explained by medical causes after history, examination, labs, tests
Onset before age 30
Symptoms tend to be chronic and complete remission is rare
* Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Question 10

Conversion Disorder

Answer 10

1. Sudden and dramatic loss of one or more voluntary motor and/or sensory functions suggesting a neurologic etiology
2. Preceded by psychological stress or conflict – the presenting symptom tends to have a symbolic relationship with the stressor and serves to decrease anxiety associated with it
   Examples
   Seeing something violent = blindness
   Shooting someone in self defense = right arm paralysis
   Group Conversions?
3. “La belle indifference” is common where patient seems uncaring/unconcerned about their remarkable symptoms
4. Usually self-limited with remission in <1 month
5. More common in the psychiatrically unsophisticated and those with depression or histrionic personality traits
6. • Unconscious, no secondary gain, patient aware of loss and symptom generation,

Question 11

Hypochondriasis (DSM IV only)

Answer 11

Renamed Illness anxiety disorder (DSM V): high health anxiety without somatic symptoms (unlike somatic symptom disorder where there is worry and somatic symptoms) –> fear of having serious illness

Question 12

hypochondriasis (illness anxiety disorder) is

Answer 12

unconscious, no secondary gain

Question 13

Body Dysmorphic Disorder(BDD)

Answer 13

1. Preoccupation with an imagined problem or insignificant abnormality in appearance – usually involving the face or head
   - Examples
   Nose to big/crooked, breasts /body not symmetrical, muscles not symmetrical, too small (adonis complex)
2. Cannot be accounted for by an eating disorder
   Anorexics are body dysmorphic thinking they are overweight
3. Plastic surgery or medical interventions rarely relieve symptoms but are commonplace
4. • Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Question 14

Pain Disorder (DSM IV only)

Answer 14

Protracted pain that is severe enough to cause the patient to seek medical attention
Cannot be explained by physical causes
Acute (<6 months) or chronic (≥6 months)
Typical age of onset during 3rd or 4th decade of life
Can be disabling and cause dependence on pain medications
* Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Question 15

Differential Diagnosis for pain disorder

Answer 15

Must rule out true unidentified organic illness!
Depression and anxiety can be great pretenders of many medical illnesses
Factitious disorders and malingering (will be covered later) differ as they are consciously driven, feigned, created where all of these so far are unconscious and without clear secondary gain

Question 16

Factitious Disorder

Answer 16

Formerly known as Münchausen syndrome
‘by Proxy’ if you create medical problems in others
Unknown whether or not this is a true somatic disorder
Conscious feigning or production of physical or mental illness in order to receive attention from medical personnel – to assume the “sick” role, a primary gain to feel safe and cared for, possible secondary gain to feel proud, an expert, able to figure things out that doctors cannot
Get angry and leave quickly when confronted
More common in people who work in the medical field
Tends to have a negative impact on work, school, and/or social functioning

Question 17

Factitious Disorder by Proxy

Answer 17

Most commonly, a parent feigns or induces illness in a child to gain attention for him or herself
Considered a form of child abuse and must be reported!
The parent may have a history of childhood abuse/neglect or serious childhood illness during which he or she felt cared for and protected by medical personnel
Or may like being the expert in his/her child’s care

Question 18

Malingering (DSM IV only)

Answer 18

NOT a psychiatric illness!
Could be a crime
Conscious simulation or exaggeration of physical or mental illness to achieve some sort of secondary gain
Disability
Drugs in the ER
Leave of absence/ AWOL
Symptoms improve as soon as the secondary gain is obtained
Seen more frequently in the incarcerated and people involved in lawsuits

Question 19

Best treatment is lengthy but

Answer 19

to obtain records from everywhere, talk to as many providers and family members as possible, frequent focused medical visits(Not psych ones), avoid over medicalizing or procedurizing the patient, have one managing PCP that must clear all procedures and referrals to specialists… simplify everything