Somatoform Disorders Flashcards
what is the most common symptom seen in somatic symptom disorder
pain
often is severe and the only symptom
what is the estimated prevalence of somatic symptom disorder
not sure but around 5-7%
is there a gender difference in somatic symptom disorder
yes, more women
what are common comorbidities with somatic symptom disorder
anxiety and depression
list general risk factors for somatic symptom disorder
- lower education
- low SES
- ACEs
- recent stressful life events
criterion A for somatic symptom disorder
1 or more SOMATIC symptoms that are DISTRESSING or result in significant disruption of daily life
criterion B for somatic symptom disorder
EXCESSIVE thoughts, feelings or behaviours related to the somatic symptom or associated health concerns as manifested by as least ONE of the following:
- disproportionate and persistent thoughts about the seriousness of one’s symptoms
- persistently high level of anxiety about health or symptoms
- excessive time and energy devoted to these symptoms or health concerns
criterion C for somatic symptom disorder
duration–> PERSISTENT (typically more than 6 mo)
*any 1 symptom may not be continuously present, the state of being symptomatic is persistent
what are the most common somatic symptoms in children
abdominal pain
headache
fatigue
nausea
what is one factor that may determine level of associated distress related to the somatic symptom in children
parents response to the symptom
what are the two specifiers for somatic symptom disorder
- with predominant pain–> (previously known as pain disorder); for those whose somatic symptoms primarily involve pain
- persistent–> severe symptoms, marked impairment, long duration (more than 6 mo)
what is mild somatic symptom disorder
only 1 or criterion B symptoms fulfilled
what is moderate somatic symptom disorder
2+ criterion B symptoms fulfilled
what is severe somatic symptom disorder
2+ criterion B symptoms + multiple somatic complaints or one very severe symptom
what associated symptoms may there be with somatic symptom disorder
repeated checking for bodily abnormalities
repeated seeking of medical help and reassurance
avoidance of physical activity
what is generally felt to cause the large part of the functional impairment seen in somatic symptom disorder
not the somatic symptom per se, but instead the way the individual presents and INTERPRETS them which causes sig. distress
ddx somatic symptom disorder
other medical conditions
panic disorder
delusional disorder
conversion disorder
BDD
GAD
depressive disorders
OCD
illness anxiety disorder
what differentiates somatic symptom disorder from illness anxiety disorder
extensive worries about health but NO or minimal somatic symptoms, then illness anxieyt disorder likely better dx
what are the goals of treatment for somatic symptom disorder
reduce anxiety and distress related to the somatic symptoms
“your suffering is real and i want to help”
how might you approach care of someone with somatic symptom disorder
reduce anxiety and distress
validate suffering
avoid unnecesssary medical investigations, treatments and medications
regularly schedule follow up appts, non contingent on rpesence of sx (might be helpful)
what psychotherapy is recommended for treatment of somatic symptom disorder
CBT and mindfulness (i.e CBT for chronic pain)
**Cochrane review: only CBT has sustained (modest) efficacy
focusing on relaxation and distraction techniques can also be helpful
is pharmacotherapy recommended for somatic symptom disorder
SSRIs–> limited evidence that may help reduce affect instability and comorbid mood and anx. symptoms
SSRIS do NOT improve somatic symptoms themselves
(though duloxetine might be helpful in fibromyalgia types pain)
teens who somatize have an increased risk of dx of somatoform disorder in adulthood if they have what risk factors
- female
- comorbid psych disorders
- parents had psych disorders
- negative life events
survivors of trauma have increased risk of somatoform disorders if they have what factors
- difficulty regulating affect
- early exposure to sexual abuse > physical abuse
- recurrent exposure to trauma > single event
list three other risk factors that may affect risk of developing somatoform disorder
- alexithymia
- attachment disorders
- chronic or comorbid disease
does reassurance from physicians help in somatic symptom disorder
tends to be short lived and/or is experienced by the individual as the doctor not taking their symptoms seriously
what is illness anxiety disorder
characterized by PREOCCUPATION with having or acquiring a SERIOUS, UNDIAGNOSED MEDICAL ILLNESS
somatic symptoms either not present or mild in intensity
think if it as GAD but with focus exclusively on health concerns
what is the estimated prevalence of illness anxiety disorder
1.3-10% (not clear)
in ambulatory medical populations, prevalence is 3-8%
is there a gender difference in illness anxiety disorder
no, equal
what is the course of illness anxiety disorder
not clear–> considered CHRONIC and RELAPSING condition with onset in early and middle ADULTHOOD
what might be the focus of worries in illness anxiety disorder in older age
memory loss
what % of people with illness anxiety disorder have a TRANSIENT form that is less severe
1/3-1/2
this form is assoc. with less psych comorbidity
what % of those with illness anxiety disorder also have another psych disorder
66%
what are the most commonly comorbid conditions with illness anxiety disorder
anxiety disorders–> GAD, panic, OCD
somatic symptom disorder
personality disorders, especially cluster C
risk factors for illness anxiety disorder
major life stress
serious but ultimately benign threat to individuals health
childhood abuse
serious childhood illnesses
criterion A for illness anxiety disorder
preoccupation with having or acquiring a serious illness
criterion B for illness anxiety disorder
somatic symptoms are not present or are only mild in intensity
IF another med condition is present OR there is a high risk for developing am medical condition (i.e strong family history), the preoccupation is clearly EXCESSIVE or DISPROPORTIONATE
criterion C for illness anxiety disorder
high level of anxiety about health
individual is easily alarmed about personal health status
criterion D for illness anxiety disorder
performs excessive health-related behaviours (i.e repeatedly checks body for signs of illness) or exhibits maladaptive avoidance (i.e avoids doctor appts)
criterion E for illness anxiety disorder
present for at least 6 months
criterion F for illness anxiety disorder
not better explained by another mental disorder
what are the two specifiers for illness anxiety disorder
- care seeking type
- care avoiding type
are people with illness anxiety disorder reassured by negative tests, benign course etc..
no–> the concern abotu undiagnosed illness does NOT respond to appropriate medical reassurance
ddx illness anxiety disorder
other medical conditions
OCD and related disorders
adjustment disorder
non-pathological health anxiety
somatic symptom disorder
MDD
psychotic disorders
anxiety disorders
what is the first thing to consider in someone with illness anxiety disorder
rule out underlying med condition including neuro or endocrine conditions, occult malignancies, other diseases that affect multiple body systems
(if med condition is present, health related anxiety is clearly disproportionate/excessive for condition’s seriousness)
what is a good approach to managing the patient with illness anxiety disorder
- regularly schedule follow up appts, non contingent on the presence of symptoms (may he helpful)
- avoid unwarranted investigations, treatment, medications (“de-medicalize” interactions when appropriate)
- avoid invalidating the person’s experience
what psychotherapeutic interventions may be helpful in illness anxiety disorder
CBT
exposure therapy
what pharmacotherapy may be effective in illness anxiety disorder
SSRIs ie fluoxetine (targets the anxiety)
what is conversion disorder
mental disorder characterized by neurologic symptoms (either motor or sensory) that is incompatible with any known neurologic disease
i.e weakness/paralysis, non epileptic seizures, movement disorders, visual impairment
what % of patients seen in neurology clinics have symptoms that are either not at all or only partly explained by structural neurologic disease
about 30%
was is the estimated incidence of conversion disorder
4-12/100 000
what is the average age at onset for conversion disorder
between 35-50 years old
what % of people with conversion disorder also have a comorbid neurological disorder
about 25%
what % of people with conversion disorder have had a physical injury preceding symptom onset
about 37%
criterion A for conversion disorder
ONE or more symptoms of altered VOLUNTARY motor or sensory function
*autonomic symptoms such as orthostatic lightheadedness would NOT meet criterion A
criterion B for conversion disorder
clinical findings provide evidence of INCOMPATIBILITY between the symptom and recognized neurological or medical conditions
criterion C + D for conversion disorder
symptom or deficit is not better explained by another medical or mental disorder
clinically significant distress/impairment
what are the two types of specifiers available for conversion disorder in the DSM
- symptom type specifiers
- episode and stressor specifier
what are the 8 symptom type specifiers for conversion disorder in the DSM
- with weakness or paralysis
- with abnormal movement (i.e gait disorder, dystonic movement, tremor, myoclonus)
- with swallowing symptoms
- with speech symptoms (i.e aphasia, slurred speech, dysphonia)
- with seizure attacks or seizures
- with anesthesia or sensory loss
- with special sensory symptom
- with mixed symptoms
what are the episode and stressor specifiers available for conversion disorder in the DSM
acute episode–> less than 6 months
persistent–> more than 6 months
with psychological stressor (+specify stressor)
without psychological stressor
is pain part of the diagnostic criteria for conversion disorder
no
how is the diagnosis of conversion disorder made
though identification of POSITIVE SYMPTOMS (i.e symptoms that resolve with distraction) rather than as a diagnosis of exclusion
how do symptoms of conversion disorder change when the patient is distracted
there is usually a reduction or even disappearance of the movement disorder
ddx conversion disorder
another mental disorder
neurological disease
–> *main differential
somatic symptom disorder
factitious disorder
malingering
dissociative disorders
BDD
depressive disorders
can conversion disorder and somatic symptom disorder be diagnosed together
yes
does the diagnosis of conversion disorder require the judgment that the symptoms are not intentionally produced
no–> assessment of conscious intent is not unreliable
what is Hoover’s sign
when weakness of hip extension returns to normal strength with contralateral hip flexion against resistance
what is the tremor entrainment test
a unilateral tremor may be functional if the tremor changes when the individual is distracted away from it
may be observed if the individual is asked to copy the examiner in making a rhythmical movement with their unaffected hand and this causes the functional tremor to change such that it copies or “entrains” to the rhythm of the unaffected hand or the functional tremor is suppressed or no longer makes a simple rhythmical movement
what are some clues on physical exam that someone is presenting with psychogenic seizures
drop arm test can be useful as clinical clue (clinician drops arm over patients face)
occurrence of closed eyes with resistance to opening suggests psychogenic seizure
normal simultaneous EEG suggests psychogenic seizure (but does not exclude all forms of epilepsy or syncope)
pupillary and gag reflexes retained post pseudoseizure suggests psychogenic etiology
what type of visual field deficit suggests conversion disorder
tubular vision field
what two elements of physical examination suggest functional etiology in a patient reporting severe monocular or binocular limitations
normal visual evoked potentials
+
normal neuro-ophthalmic exam
normal pupillary reflexes + preserved optokinetic nystagmus suggest grossly intact subcortical and cortical pathways and therefore functional etiology
what type of testing is often needed to confirm diagnosis of functional blindness, and why
to rule out cortical pathology including cortical blindness
electrophysiological testing + structural neuroimaging is needed
what type of psychotherapy has evidence in conversion disorder and what level of evidence does it have
CBT
second line evidence
what is the MOST IMPORTANT first line treatment for conversion disorder
education and self help technique
*remind patient that conversion disorder is treatable condition
disorder of the “function” i.e SOFTWARE rather than the “structure” i.e the hardware
is there a large role for medications in conversion disorder
only limited role
what type of treatment is recommended for physical symptoms of conversion disorder
physical therapy
gradual and graded approach
what type of symptoms are often associated with conversion symptoms, especially at conversion symptom onset or during attacks
dissociative symptoms
in what situations is conversion disorder in men often seen
after industrial accidents or in the military
conversion disorder has association with what type of personality disorder
antisocial PD
what phenomenon may be seen in patients with conversion disorder
la belle indifference towards their symptoms
what % of people with conversion disorder also have depressive disorder
at least 50%
what % of people with conversion disorder also have anxiety disorders
30-50% (esp. panic)
what % of people with conversion disorder also have dissociative disorder
45-80%
is conversion disorder more common in women or men
2-3x more common in women
onset of nonepileptic attacks peaks in frequency in what decade of life
3rd decade
*but most symptoms have peak onset in 4th decade
what is the typical course of conversion disorder
varies but onset is usually sudden and associated with stressor then resolves within 6 months of onset
what 3 factors offer good prognosis for conversion disorder
good premorbid functioning
rapid onset
clear trigger
what is the most important feature of therapy in treatment of conversion disorder
rapport
how does conversion disorder usually resolve
usually spontaneous resolution
in “psychological factors affecting other medical conditions,” what are some of the possible psychological factors considered in the DSM
psychological distress
patterns of interpersonal interaction
coping styles
maladaptive health behaviours (i.e denial of symptoms, poor adherence to medical recs)
i.e anxiety exacerbating asthma, denial of need for treatment of acute chest pain, manipulation of insulin by person with diabetes wishing to lose weight
i.e symptoms of depression or anxiety, stressful life events, relationship style, personality traits, coping styles
what is one example of a “psychological factors affecting other medical conditions” that can be acute, with immediate medical consequences
Takostubo cardiomyopathy
what are the criteria for “psychological factors affecting other medical conditions”
A–> A medical symptom or condition (other than a mental disorder) is present.
B–> Psychological or behavioral factors adversely affect the medical condition in one of the following ways:
1. The factors have influenced the course of the medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition.
- The factors interfere with the treatment of the medical condition (e.g., poor adherence).
- The factors constitute additionalwell-established health risks for the individual.
- The factors influence the underlying pathophysiology, precipitating or exacerbating symptomsor necessitating medical attention.
C–> The psychological and behavioral factors in Criterion B are not better explained by another mental disorder (e.g., panic disorder, major depressive disorder, posttraumatic stress disorder).”
Specify current severity:
Mild: Increases medical risk (e.g., inconsistent adherence with antihypertension treatment).
Moderate: Aggravates underlying medical condition (e.g., anxiety aggravating asthma).
Severe: Results in medical hospitalization or emergency room visit.
Extreme: Results in severe, life-threatening risk (e.g., ignoring heart attack symptoms).
the diagnosis of “psychological factors affecting other medical conditions” should be reserved for what types of situations
situations in which the EFFECT of the psychological factor on the medical condition is EVIDENT and the psychological factor has clinically significant effects on the COURSE OR OUTCOME of the medical condition
*abnormal psychological or behavioural symptoms that develop IN RESPONSE to a medical condition are better coded as an adjustment disorder
what is factitious disorder
“munchausen syndrome”
falsification of physical or psychological signs or symptoms with no obvious reward
patients are AWARE they are exagerrating
in hospital settings, what % of people are estimated to be presenting with factitious disorder
about 1%
factitious disorder is more common amongst which populations
women and healthcare workers
which populations are more likely to be perpetrators of munchausens by proxy
almost all perpetrators are female
more than 95% of perpetrators are the MOTHER
what is the overall prognosis for factitious disorder
generally poor
when confronted, majority of individuals will deny their behaviours and very few will seek treatment
what is the mortality rate for the victims of factitious disorder imposed on another (munchausens by proxy)
6-22%
what are the most common forms of harm in factitious disorder imposed on another
poisoning and suffocation
when does factitious disorder imposed on another typically begin
after an initial hospitalization of the individuals child or other dependent for legitimate reasons
when does factitious disorder usually begin
often first onset in early adulthood
often following a hospitalization for medical or psychiatric reasons
individuals often have a history of multiple hospitalizations and are willing to undergo invasive procedures
list risk factors for factitious disorder
may have hx abuse/neglect as a child
may have exprienced true medical condition that lead to extensive treatment in childhood, past important relationships with a physician or may have underlying malicious intent towards the medical profession
what disorders are commonly comorbid with factitious disorder
personality disorders
in factitious disorder imposed on another, also high comorbidity with PDs, somatoform disorders, mood disorders in the perp
what are the criteria for factitious disorder imposed on self
A–> Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B–> The individual presents himself or herself to others as ill, impaired, or injured.
C–> The deceptive behavior is evident even in the absence of obvious external rewards.
D–> The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
Specify:
Single episode
Recurrent episodes (two or more events of falsification of illness and/or induction of injury)
what are the criteria for factitious disorder imposed on another
A–> Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
B–> The individual presents another individual (victim) to others as ill, impaired, or injured.
C–> The deceptive behavior is evident even in the absence of obvious external rewards.
D–> The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
Note: The perpetrator, not the victim, receives this diagnosis.
Specify:
Single episode
Recurrent episodes (two or more events of falsification of illness and/or induction of injury)
what differentiates factitious disorder from malingering
the absence of obvious rewards for the deception
what is the first treatment goal for factitious disorder
modify individuals behaviour and reduce misuse or overuse of the medical system
what is the primary treatment for factitious disorder
psychotherapy (including psychoanalytic or psychodynamic therapy, CBT, family therapy)
any underlying psychiatric disorder should be identified and treated
what is the most commonly comorbid mood disorder with factitious disorder
MDD
what are the 3 most commonly comorbid personality disorders with factitious disorder
BPD
ASPD
NPD
what are the guidelines for treatment of factitious disorder according to K&S
- active pursuit of prompt diagnosis can mitigate risk of morbidity and mortality
- minimize harm–> avoid unnecessary tests and procedures, esp. if invasive; treat according to clinical judgment keeping inmind subjective complaints may be deceptive
- regular interdisciplinary meetings to reduce conflict and splitting amongst staff; manage staff countertransference
- consider facilitating healing by using the DOUBLE-BLIND technique or face-saving behavioural strategies such as SELF-HYPNOSIS or BIOFEEDBACK
- steer patient towards psych tx in empathetic, nonconfrontational, face saving manner–> avoid aggressive direct confrontation
- treat underlying psych disturbances
- in psychotherapy, address coping strategies and emotional conflicts
- appoint a primary care provider as a gatekeeper for all medical and psychiatric treatment
- consider involving RISK MANAGEMENT professionals and bioethicists from an early point
- consider appointing a GUARDIAN for medical and psychiatric decisions
- consider prosecution for FRAUD, as a behavioural disincentive
list some interventions appropriate for factitious disorder by proxy
- pediatrician should serve as a gatekeeper for medical care utilization (all other physicians should coordinate with this doc)
- child protective services should be informed whenever a child is harmed
- family psychotherapy and/or individual psychotherapy should be instituted for the perpetrating parent and the child
- health insurance companies, school officials, and other nonmedical sources should be asked to report possible medical use to the physician gatekeeper–> permission of parent or of CPS must first be obtained
- the possibility should be considered of admitting child to inpatient or partial hpsital setting to facilitate dx monitoring of sx and to institute tx plan
- child may require placement in another family
list the 4 “other specifies somatic symptom and related disorders” listed in the DSM
- brief somatic symptom disorder
- brief illness anxiety disorder
- illness anxiety disorder without excessive. health related behaviours
- pseudocyesis
what is pseudocyesis
false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy
