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20. Sexual, Gender, Somatoform, Paraphilic Disorders > Somatoform Disorders > Flashcards

Somatoform Disorders Flashcards

1
Q

what is the most common symptom seen in somatic symptom disorder

A

pain

often is severe and the only symptom

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2
Q

what is the estimated prevalence of somatic symptom disorder

A

not sure but around 5-7%

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3
Q

is there a gender difference in somatic symptom disorder

A

yes, more women

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4
Q

what are common comorbidities with somatic symptom disorder

A

anxiety and depression

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5
Q

list general risk factors for somatic symptom disorder

A
  1. lower education
  2. low SES
  3. ACEs
  4. recent stressful life events
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6
Q

criterion A for somatic symptom disorder

A

1 or more SOMATIC symptoms that are DISTRESSING or result in significant disruption of daily life

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7
Q

criterion B for somatic symptom disorder

A

EXCESSIVE thoughts, feelings or behaviours related to the somatic symptom or associated health concerns as manifested by as least ONE of the following:

  1. disproportionate and persistent thoughts about the seriousness of one’s symptoms
  2. persistently high level of anxiety about health or symptoms
  3. excessive time and energy devoted to these symptoms or health concerns
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8
Q

criterion C for somatic symptom disorder

A

duration–> PERSISTENT (typically more than 6 mo)

*any 1 symptom may not be continuously present, the state of being symptomatic is persistent

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9
Q

what are the most common somatic symptoms in children

A

abdominal pain

headache

fatigue

nausea

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10
Q

what is one factor that may determine level of associated distress related to the somatic symptom in children

A

parents response to the symptom

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11
Q

what are the two specifiers for somatic symptom disorder

A
  1. with predominant pain–> (previously known as pain disorder); for those whose somatic symptoms primarily involve pain
  2. persistent–> severe symptoms, marked impairment, long duration (more than 6 mo)
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12
Q

what is mild somatic symptom disorder

A

only 1 or criterion B symptoms fulfilled

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13
Q

what is moderate somatic symptom disorder

A

2+ criterion B symptoms fulfilled

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14
Q

what is severe somatic symptom disorder

A

2+ criterion B symptoms + multiple somatic complaints or one very severe symptom

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15
Q

what associated symptoms may there be with somatic symptom disorder

A

repeated checking for bodily abnormalities

repeated seeking of medical help and reassurance

avoidance of physical activity

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16
Q

what is generally felt to cause the large part of the functional impairment seen in somatic symptom disorder

A

not the somatic symptom per se, but instead the way the individual presents and INTERPRETS them which causes sig. distress

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17
Q

ddx somatic symptom disorder

A

other medical conditions

panic disorder

delusional disorder

conversion disorder

BDD

GAD

depressive disorders

OCD

illness anxiety disorder

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18
Q

what differentiates somatic symptom disorder from illness anxiety disorder

A

extensive worries about health but NO or minimal somatic symptoms, then illness anxieyt disorder likely better dx

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19
Q

what are the goals of treatment for somatic symptom disorder

A

reduce anxiety and distress related to the somatic symptoms

“your suffering is real and i want to help”

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20
Q

how might you approach care of someone with somatic symptom disorder

A

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)

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21
Q

what psychotherapy is recommended for treatment of somatic symptom disorder

A

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

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22
Q

is pharmacotherapy recommended for somatic symptom disorder

A

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)

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23
Q

teens who somatize have an increased risk of dx of somatoform disorder in adulthood if they have what risk factors

A
  1. female
  2. comorbid psych disorders
  3. parents had psych disorders
  4. negative life events
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24
Q

survivors of trauma have increased risk of somatoform disorders if they have what factors

A
  1. difficulty regulating affect
  2. early exposure to sexual abuse > physical abuse
  3. recurrent exposure to trauma > single event
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25
Q

list three other risk factors that may affect risk of developing somatoform disorder

A
  1. alexithymia
  2. attachment disorders
  3. chronic or comorbid disease
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26
Q

does reassurance from physicians help in somatic symptom disorder

A

tends to be short lived and/or is experienced by the individual as the doctor not taking their symptoms seriously

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27
Q

what is illness anxiety disorder

A

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

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28
Q

what is the estimated prevalence of illness anxiety disorder

A

1.3-10% (not clear)

in ambulatory medical populations, prevalence is 3-8%

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29
Q

is there a gender difference in illness anxiety disorder

A

no, equal

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30
Q

what is the course of illness anxiety disorder

A

not clear–> considered CHRONIC and RELAPSING condition with onset in early and middle ADULTHOOD

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31
Q

what might be the focus of worries in illness anxiety disorder in older age

A

memory loss

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32
Q

what % of people with illness anxiety disorder have a TRANSIENT form that is less severe

A

1/3-1/2

this form is assoc. with less psych comorbidity

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33
Q

what % of those with illness anxiety disorder also have another psych disorder

A

66%

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34
Q

what are the most commonly comorbid conditions with illness anxiety disorder

A

anxiety disorders–> GAD, panic, OCD

somatic symptom disorder

personality disorders, especially cluster C

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35
Q

risk factors for illness anxiety disorder

A

major life stress

serious but ultimately benign threat to individuals health

childhood abuse

serious childhood illnesses

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36
Q

criterion A for illness anxiety disorder

A

preoccupation with having or acquiring a serious illness

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37
Q

criterion B for illness anxiety disorder

A

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

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38
Q

criterion C for illness anxiety disorder

A

high level of anxiety about health

individual is easily alarmed about personal health status

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39
Q

criterion D for illness anxiety disorder

A

performs excessive health-related behaviours (i.e repeatedly checks body for signs of illness) or exhibits maladaptive avoidance (i.e avoids doctor appts)

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40
Q

criterion E for illness anxiety disorder

A

present for at least 6 months

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41
Q

criterion F for illness anxiety disorder

A

not better explained by another mental disorder

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42
Q

what are the two specifiers for illness anxiety disorder

A
  1. care seeking type
  2. care avoiding type
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43
Q

are people with illness anxiety disorder reassured by negative tests, benign course etc..

A

no–> the concern abotu undiagnosed illness does NOT respond to appropriate medical reassurance

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44
Q

ddx illness anxiety disorder

A

other medical conditions

OCD and related disorders

adjustment disorder

non-pathological health anxiety

somatic symptom disorder

MDD

psychotic disorders

anxiety disorders

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45
Q

what is the first thing to consider in someone with illness anxiety disorder

A

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)

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46
Q

what is a good approach to managing the patient with illness anxiety disorder

A
  1. regularly schedule follow up appts, non contingent on the presence of symptoms (may he helpful)
  2. avoid unwarranted investigations, treatment, medications (“de-medicalize” interactions when appropriate)
  3. avoid invalidating the person’s experience
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47
Q

what psychotherapeutic interventions may be helpful in illness anxiety disorder

A

CBT

exposure therapy

48
Q

what pharmacotherapy may be effective in illness anxiety disorder

A

SSRIs ie fluoxetine (targets the anxiety)

49
Q

what is conversion disorder

A

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

50
Q

what % of patients seen in neurology clinics have symptoms that are either not at all or only partly explained by structural neurologic disease

A

about 30%

51
Q

was is the estimated incidence of conversion disorder

A

4-12/100 000

52
Q

what is the average age at onset for conversion disorder

A

between 35-50 years old

53
Q

what % of people with conversion disorder also have a comorbid neurological disorder

A

about 25%

54
Q

what % of people with conversion disorder have had a physical injury preceding symptom onset

A

about 37%

55
Q

criterion A for conversion disorder

A

ONE or more symptoms of altered VOLUNTARY motor or sensory function

*autonomic symptoms such as orthostatic lightheadedness would NOT meet criterion A

56
Q

criterion B for conversion disorder

A

clinical findings provide evidence of INCOMPATIBILITY between the symptom and recognized neurological or medical conditions

57
Q

criterion C + D for conversion disorder

A

symptom or deficit is not better explained by another medical or mental disorder

clinically significant distress/impairment

58
Q

what are the two types of specifiers available for conversion disorder in the DSM

A
  1. symptom type specifiers
  2. episode and stressor specifier
59
Q

what are the 8 symptom type specifiers for conversion disorder in the DSM

A
  1. with weakness or paralysis
  2. with abnormal movement (i.e gait disorder, dystonic movement, tremor, myoclonus)
  3. with swallowing symptoms
  4. with speech symptoms (i.e aphasia, slurred speech, dysphonia)
  5. with seizure attacks or seizures
  6. with anesthesia or sensory loss
  7. with special sensory symptom
  8. with mixed symptoms
60
Q

what are the episode and stressor specifiers available for conversion disorder in the DSM

A

acute episode–> less than 6 months

persistent–> more than 6 months

with psychological stressor (+specify stressor)

without psychological stressor

61
Q

is pain part of the diagnostic criteria for conversion disorder

A

no

62
Q

how is the diagnosis of conversion disorder made

A

though identification of POSITIVE SYMPTOMS (i.e symptoms that resolve with distraction) rather than as a diagnosis of exclusion

63
Q

how do symptoms of conversion disorder change when the patient is distracted

A

there is usually a reduction or even disappearance of the movement disorder

64
Q

ddx conversion disorder

A

another mental disorder

neurological disease
–> *main differential

somatic symptom disorder

factitious disorder

malingering

dissociative disorders

BDD

depressive disorders

65
Q

can conversion disorder and somatic symptom disorder be diagnosed together

A

yes

66
Q

does the diagnosis of conversion disorder require the judgment that the symptoms are not intentionally produced

A

no–> assessment of conscious intent is not unreliable

67
Q

what is Hoover’s sign

A

when weakness of hip extension returns to normal strength with contralateral hip flexion against resistance

68
Q

what is the tremor entrainment test

A

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

69
Q

what are some clues on physical exam that someone is presenting with psychogenic seizures

A

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

70
Q

what type of visual field deficit suggests conversion disorder

A

tubular vision field

71
Q

what two elements of physical examination suggest functional etiology in a patient reporting severe monocular or binocular limitations

A

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

72
Q

what type of testing is often needed to confirm diagnosis of functional blindness, and why

A

to rule out cortical pathology including cortical blindness

electrophysiological testing + structural neuroimaging is needed

73
Q

what type of psychotherapy has evidence in conversion disorder and what level of evidence does it have

A

CBT

second line evidence

74
Q

what is the MOST IMPORTANT first line treatment for conversion disorder

A

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

75
Q

is there a large role for medications in conversion disorder

A

only limited role

76
Q

what type of treatment is recommended for physical symptoms of conversion disorder

A

physical therapy

gradual and graded approach

77
Q

what type of symptoms are often associated with conversion symptoms, especially at conversion symptom onset or during attacks

A

dissociative symptoms

78
Q

in what situations is conversion disorder in men often seen

A

after industrial accidents or in the military

79
Q

conversion disorder has association with what type of personality disorder

A

antisocial PD

80
Q

what phenomenon may be seen in patients with conversion disorder

A

la belle indifference towards their symptoms

81
Q

what % of people with conversion disorder also have depressive disorder

A

at least 50%

82
Q

what % of people with conversion disorder also have anxiety disorders

A

30-50% (esp. panic)

83
Q

what % of people with conversion disorder also have dissociative disorder

A

45-80%

84
Q

is conversion disorder more common in women or men

A

2-3x more common in women

85
Q

onset of nonepileptic attacks peaks in frequency in what decade of life

A

3rd decade

*but most symptoms have peak onset in 4th decade

86
Q

what is the typical course of conversion disorder

A

varies but onset is usually sudden and associated with stressor then resolves within 6 months of onset

87
Q

what 3 factors offer good prognosis for conversion disorder

A

good premorbid functioning

rapid onset

clear trigger

88
Q

what is the most important feature of therapy in treatment of conversion disorder

A

rapport

89
Q

how does conversion disorder usually resolve

A

usually spontaneous resolution

90
Q

in “psychological factors affecting other medical conditions,” what are some of the possible psychological factors considered in the DSM

A

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

91
Q

what is one example of a “psychological factors affecting other medical conditions” that can be acute, with immediate medical consequences

A

Takostubo cardiomyopathy

92
Q

what are the criteria for “psychological factors affecting other medical conditions”

A

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.

  1. The factors interfere with the treatment of the medical condition (e.g., poor adherence).
  2. The factors constitute additionalwell-established health risks for the individual.
  3. 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).

93
Q

the diagnosis of “psychological factors affecting other medical conditions” should be reserved for what types of situations

A

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

94
Q

what is factitious disorder

A

“munchausen syndrome”

falsification of physical or psychological signs or symptoms with no obvious reward

patients are AWARE they are exagerrating

95
Q

in hospital settings, what % of people are estimated to be presenting with factitious disorder

A

about 1%

96
Q

factitious disorder is more common amongst which populations

A

women and healthcare workers

97
Q

which populations are more likely to be perpetrators of munchausens by proxy

A

almost all perpetrators are female

more than 95% of perpetrators are the MOTHER

98
Q

what is the overall prognosis for factitious disorder

A

generally poor

when confronted, majority of individuals will deny their behaviours and very few will seek treatment

99
Q

what is the mortality rate for the victims of factitious disorder imposed on another (munchausens by proxy)

A

6-22%

100
Q

what are the most common forms of harm in factitious disorder imposed on another

A

poisoning and suffocation

101
Q

when does factitious disorder imposed on another typically begin

A

after an initial hospitalization of the individuals child or other dependent for legitimate reasons

102
Q

when does factitious disorder usually begin

A

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

103
Q

list risk factors for factitious disorder

A

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

104
Q

what disorders are commonly comorbid with factitious disorder

A

personality disorders

in factitious disorder imposed on another, also high comorbidity with PDs, somatoform disorders, mood disorders in the perp

105
Q

what are the criteria for factitious disorder imposed on self

A

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)

106
Q

what are the criteria for factitious disorder imposed on another

A

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)

107
Q

what differentiates factitious disorder from malingering

A

the absence of obvious rewards for the deception

108
Q

what is the first treatment goal for factitious disorder

A

modify individuals behaviour and reduce misuse or overuse of the medical system

109
Q

what is the primary treatment for factitious disorder

A

psychotherapy (including psychoanalytic or psychodynamic therapy, CBT, family therapy)

any underlying psychiatric disorder should be identified and treated

110
Q

what is the most commonly comorbid mood disorder with factitious disorder

A

MDD

111
Q

what are the 3 most commonly comorbid personality disorders with factitious disorder

A

BPD

ASPD

NPD

112
Q

what are the guidelines for treatment of factitious disorder according to K&S

A
  1. active pursuit of prompt diagnosis can mitigate risk of morbidity and mortality
  2. minimize harm–> avoid unnecessary tests and procedures, esp. if invasive; treat according to clinical judgment keeping inmind subjective complaints may be deceptive
  3. regular interdisciplinary meetings to reduce conflict and splitting amongst staff; manage staff countertransference
  4. consider facilitating healing by using the DOUBLE-BLIND technique or face-saving behavioural strategies such as SELF-HYPNOSIS or BIOFEEDBACK
  5. steer patient towards psych tx in empathetic, nonconfrontational, face saving manner–> avoid aggressive direct confrontation
  6. treat underlying psych disturbances
  7. in psychotherapy, address coping strategies and emotional conflicts
  8. appoint a primary care provider as a gatekeeper for all medical and psychiatric treatment
  9. consider involving RISK MANAGEMENT professionals and bioethicists from an early point
  10. consider appointing a GUARDIAN for medical and psychiatric decisions
  11. consider prosecution for FRAUD, as a behavioural disincentive
113
Q

list some interventions appropriate for factitious disorder by proxy

A
  1. pediatrician should serve as a gatekeeper for medical care utilization (all other physicians should coordinate with this doc)
  2. child protective services should be informed whenever a child is harmed
  3. family psychotherapy and/or individual psychotherapy should be instituted for the perpetrating parent and the child
  4. 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
  5. 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
  6. child may require placement in another family
114
Q

list the 4 “other specifies somatic symptom and related disorders” listed in the DSM

A
  1. brief somatic symptom disorder
  2. brief illness anxiety disorder
  3. illness anxiety disorder without excessive. health related behaviours
  4. pseudocyesis
115
Q

what is pseudocyesis

A

false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy

20. Sexual, Gender, Somatoform, Paraphilic Disorders (4 decks)

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