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Somatoform Disorders* Flashcards

1
Q

Physical symptoms that may not be fully explained by a known medical diagnosis after appropriate work-up

A

Somatization

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2
Q

Is somatization conscious or unconscious? What might influence a patient to develop somatization?

A

May be either but usually considered unconscious
Desire to be the patient or need for personal gain

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3
Q

Up to ___ of primary care patients display at least some degree of somatization. What percent of medical/surgical patients have no known organic cause for their symptoms?

A

25%, 10%

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4
Q

How is somatization related to biological disease?

A
  • Most patients have at least some degree of biologic disease
  • somatization is an over response to symptoms

Patients believe themselves more ill than objective evidence suggests

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5
Q

What are risk factors for somatization?

A
  • Female
  • Low socioeconomic status
  • Low education
  • Minority ethnicity
  • Family member with chronic illness
  • History of abuse or trauma
  • Comorbid psych disorder
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6
Q

What are causes of somatization

A
  • Provides social support
  • Rationalization for failures of roles
  • Means of obtaining nurturance
  • Cry for help
  • Psychological disorders incorrectly attributed to physical disease
  • Less stigmatized than psychiatric illness
  • Hypersensitive to somatic symptoms
  • Learned behavior
  • Provides incentives- disability, avoidance of social responsibility
  • Physical or sexual child abuse trauma response
  • Inadvertently physician influenced by symptomatic treatment of fashionable diseases
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7
Q

What term does the ICD-10 use for somatization? DSM-V-TR?

A

ICD-10: Somatoform disorders
DSM-V-TR: somatic symptom and related disorders

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8
Q

Syndrome of multiple unexplained physical symptoms

A

Somatic Symptom Disorder

Previously referred to as somatization disorder
In past, would have been diagnosed with hypochondria, pain disorder, and somatization disorder

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9
Q

What is the prevalence of somatic symptom disorder?

A

.1-.4%
Believed to be much higher, especially in hospitalized/surgical patients

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10
Q

What patient populations is somatic symptom disorder more common in?

A
  • Female
  • Unmarried
  • Non-white
  • Poorly educated
  • Rural area
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11
Q

What is the etiology of somatic symptom disorder?

A
  • Some genetic
  • Unstable, dysfunctional family common
  • Physical symptoms to cope with repressed psych symptoms
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12
Q

What is the classic presentation of somatic symptom disorder?

A
  • Multiple unexplained physical symptoms accompanied by sense of urgency
  • Complicated medical history
  • Multiple invasive diagnostic studies/procedures/treatments
  • Commonly affecting GI, reproductive, neuro
  • Symptoms: Pain, N/V/D, bloating, dizziness, dysphagia, SOB
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13
Q

What are the diagnostic criteria for somatic symptom disorder?

A
  • 1+ somatic symptom that causes distress or disruption
  • 1+ of the following: 1) disproportionate and persistent thoughts about seriousness of symptoms 2) persistent high level of anxiety about health/symptoms 3) excessive time and energy devoted to symptoms/health concerns
  • Symptoms for >6 months
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14
Q

Somatic symptom disorder with somatic symptoms mostly related to pain

A

Somatic symptom disorder with predominant pain

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15
Q

Somatic symptom disorder with severe symptoms, marked impairment, and long duration

A

Persistent somatic symptom disorder

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16
Q

How can the severity of somatic symptom disorder be described?

A

Mild: 1 symptom
Moderate: 2+ symptoms
severe: 2+ symptoms plus multiple somatic complaints

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17
Q

what questionnaire can be used to assess for somatic symptom disorder?

A

Somatic Symptom Scale-8

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18
Q

How is somatic symptom disorder treated?

A
  • Care through one PCP with frequent, routine follow-ups
  • Avoid new or excess diagnostic studies
  • No specific pharmaceutical management, treat comorbid disorders
  • Psychotherapy- can reduce health expenditures by 50%
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19
Q

Previously referred to as conversion disorder, marked by altered voluntary motor or sensory function

A

Functional Neurological Symptom Disorder

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20
Q

What is the prevalence of functional neurological symptom disorder?

A

1-3% neurology patients
33% women
5-10% hospitalized/surgical patients referred to psych

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21
Q

What age most commonly gets functional neurological symptom disorder?

A

10-35 yo

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22
Q

what are the risk factors of functional neurological symptom disorder?

A
  • Trauma (may trigger)
  • Comorbid psych disorders
  • Lower IQ, less educated/socially sophisticated
  • Delayed verbal communication/impaired ability to articular distress
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23
Q

What is the classic presentation of functional neurological symptom disorder?

A
  • Neurological symptom (s) that do not correlate with the presence of organic disease
  • Often inconsistent or incongruent
  • Hoover’s sign
  • Common symptoms: pseudoseizures, paralysis, blindness, mutism, paresthesia, anesthesia
  • Episodic, recur with stress

Sensory, motor, or both

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24
Q

What is Hoover’s sign?

A

weakness with hip extension that becomes strong when contralateral leg is flexed

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25
How is Functional Neurological Symptom Disorder diagnosed?
1+ symptoms affecting voluntary motor or sensory function Symptoms incompatible with neurological or medical condition ## Footnote Not better explained by another condition and causes significant distress or impairs functions
26
What differential diagnosis should be considered for functional neurological symptom disorder?
other psych disease neurological disease malingering
27
What is treatment of functional neurological symptom disorder?
1. Education about disorder 2. Psychotherapy referral ## Footnote Education: symptoms often resolve spontaneously, reversal of symptoms possible, treat comorbid psych diagnoses Psychotherapy: insight-oriented or behavioral therapy
28
Condition characterized by preoccupation with a serious illness with minimal to no somatic symptoms to support this concern | `
Illness Anxiety Disorder
29
What is the prevalence of illness anxiety disorder?
2-7% of ambulatory patients
30
What gender/age is most common for illness anxiety disorder?
* equally common in men and women * MC onset age 20-30
31
What is the etiology of illness anxiety disorder?
* Unknown, no evidence of genetic * Low thresholds of physical discomfort * Learned behaviors about illness and symptoms * Often comorbid with anxiety disorders and/or depressive disorders
32
What is the classic presentation of illness anxiety disorder?
* Misinterpretation of benign symptoms * Extremely detailed histories * Fixed on one disease or move to new disease over time * Symptoms wax/wane with stress * Unswayed by negative objective findings
33
What is the criteria for diagnosis of illness anxiety disorder?
1. Preoccupation with having or getting serious illness 2. Somatic symptoms mild/not present or preoccupation with condition excessive and disproportionate 3. High anxiety and easily alarmed about health status 4. Excessive health related behaviors/maladaptive avoidance 5. Symptoms >6 months 6. Not better explained by another mental disorder ## Footnote Excessive health related behaviors or maladaptive avoidance: repeatedly checks body for signs or avoids appointments and hospitals
34
What differential diagnosis should be considered for illness anxiety disorder?
* OCD * Anxiety disorders * Other somatoform disorders * Acute medical conditions
35
How is illness anxiety disorder treated?
* Frequent, regular visits * Compassionate, tactful education on illness * Diagnostic studies only with objective evidence * Therapy if patients willing * Medications for comorbid conditions ## Footnote Patients often decline psychiatric referral
36
Condition characterized by preoccupations with perceived appearance defects
Body dysmorphic disorder
37
What is the prevalence of body dysmorphic disorder?
* 1-5% * Most seen at dermatology or plastic surgery
38
Which age/gender more commonly has body dysmorphic disorder?
* Equal male and female * 20-40 years old, many unmarried
39
Etiology of body dysmorphic disorder
* No evidence of genetic * Related to OCD * Association with social anxiety disorder and major depressive disorder
40
Classic presentation of body dysmorphic disorder
* Preoccupation with specific aspect of appearance * May be vague, imperceptible to others, hard to understand * Concern may change over time * Believe others notice more than they do * Excessively check mirrors or avoid * Attempt to hide deformity
41
Almost all patients with body dysmorphic disorder _____
Avoid public exposure/interaction * 1/3 totally housebound * 1/5 attempt suicide
42
What are common problem areas of patients with body dysmorphic disorder?
* Facial features * hair * breasts * genitalia
43
What is criteria for body dysmorphic disorder?
* Preoccupation with 1+ perceived defect/flaw in physical appearance * Repetitive behaviors or mental acts ## Footnote Causes distress or functional impairment and not better accounted for by another mental disorder
44
What are common repetitive behaviors and mental acts performed by patients with body dysmorphic disorder?
Behaviors: mirror checking, excessive grooming, skin picking, reassurance seeking Mental acts: comparing appearance to others
45
Body dysmorphic disorder with idea that muscle mass is too small
with muscle dymorphia
46
What are insight specifiers for patients with body dysmorphic disorder?
* Good or fair insight- believes disordered beliefs are not true * Poor insight- believes beliefs probably true * Absent insight/delusional beliefs- completely convinced BDD beliefs true
47
How is body dysmorphic disorder treated?
* Correction of perceived flaw almost never helpful! * SSRIs = first line pharm * Psychotherapy = CBT, cognitive restructuring with exposure therapy
48
How is somatic symptom disorder with predominant pain categorized?
Based on associated factors * Psychological * General medical condition * Psychological factors and general medical condition ## Footnote Most patients have some degree of physical disease that causes pain, but response is abnormal
49
What is the prevalence of somatic symptom with predominant pain
MC somatoform disorder * 8.1% 12 month * 12.7% lifetime
50
What gender/age is somatic symptom disorder with predominant pain most common?
* MC women * More common older (40-50)
51
What is the etiology of somatic symptom disorder with predominant pain?
* No genetic predisposition * Somatic expression of depression * Relation to guilt- deserving pain
52
Classic presentation of somatic symptom disorder with predominant pain
Focus on symptom of pain in 1+ areas * Varying types of pain * Long history of medical and surgical care * May deny other sources of negative emotion | May have medical condition, but psych factors play major role ## Footnote Not intentionally produced or feigned
53
What is DSM criteria of somatic symptom disorder with predominant pain?
* 1+ somatic symptom predominantly involving pain, causes distress or disruption * Excessive thoughts, feelings or behaviors related to somatic symptom * Symptoms >6 months
54
What are manifestations of excessive thoughts, feelings or behaviors in somatic symptom disorder with predominant pain according to DSM? | Must have 1+ of following with somatic symptom
1. Disproportionate and persistent thoughts about symptoms 2. Anxiety about health/symptoms 3. Excessive time/energy devoted to health concerns
55
What is the treatment of somatic symptom disorder with predominant pain?
* Alleviation of underlying psych symptoms/environmental factors * May have opiate addiction/dependence * NSAIDs first line if analgesics needed * Psych meds: antidepressants--> SNRIs > SSRIs, TCAs also useful ## Footnote Avoid opioids
56
Intentionally faking symptoms to assume patient role
Factitious disorder
57
General diagnosis to describe when psych or behavioral factors have a significant impact on a medical illness
Psychological factors affecting other medical disorders
58
What are general guidelines for treatment of somatic disorders?
Relationship with PCP and management of complaints
59
What are guidelines for PCP communicating with somatic conditions?
* Schedule regular visits * Acknowledge and legitimize symptoms * Reassure medical conditions are ruled out * Educate on coping with physical symptoms
60
How should complaints of somatic disorder patients be managed?
* Communicate with other providers * Evaluate and treat diagnosable disease * Limit diagnostic testing and referrals * Consider psychotherapy * Treat comorbid psych disorders/substance abuse * Goal of treatment = functional improvement * Pharmacotherapy with SSRIs, SNRIs, TCAs
61
Condition characterized by intentional faking of s/s to appear ill, impaired, or injured ## Footnote Persists without obvious rewards, motivation is assume sick role
Factitious disorder
62
Former name for factitious disorder
Munchausen syndrome
63
Intentional induction of symptoms on a victim other than the patient with the disorder ## Footnote This is form of abuse! Usually severe
Munchausen syndrome by proxy ## Footnote May be referred to as factitious disorder by proxy
64
What is the prevalence of factitious disorder?
General clinical population = 1% Psychiatric inpatients = 8%
65
What are risk factors for factitious disorder?
* Female * Unmarried * Healthcare workers * Childhood abuse ## Footnote Munchausen syndrome- male
66
Former name for factitious disorder still used to refer to especially severe cases of factitious disorder
Munchausen syndrome
67
Classic presentation of factitious disorder
* Psychological or physcial s/s of illness * Different accounts of illness to different clinicians * Evasive about history, may refuse to share records * Seen at multiple facilities by multiple providers
68
How might a patient with factitious disorder cause s/s?
* Misuse of medication * Inferfering with tests * Coaching others to correlate history * Nonadherence to care plans of existing illness * Self-inflicting injuries * Forging medical records
69
What is the DSM criteria of factitious disorder?
* Single episode or recurrent * Falsification of physical/psychological s/s * Present as ill, impaired, or injured * Deceptive behavior even in absence of rewards ## Footnote Not better explained by another mental disorder
70
What are common symptoms of factitious disorder?
* Poor wound healing, pain, seizures, hypoglycemia, GI symptoms, depression, suicidal thoughts
71
Patients with factitious disorder often agree to ______ but are strongly adverse to ______ They usually have _____ and symptoms may be ______
complex work-ups, specialty consults, and invasive procedures psychiatric consult few visitors in hospital unusual or rare
72
In the severe form of factitious disorder, patients do what?
* Have aliases and wander from clinic to clinic * Present on night/weekends with dramatic/severe symptoms, extraordinary history, and inconsistent findings * Fail to respond to standard treatment * Become upset or angry when confronted
73
What is the classic presentation of factitious disorder imposed on another?
* Mother inflicting symptoms of illness onto child
74
What are clues to diagnosis of factitious disorder imposed on another?
* Incongruent history * Recurrent, unexplained, prolonged, unusual illness * Limited/no response to standard therapy * S/s worsen when victim around perp or when about to be discharged * S/s improve when victim not around perp, lack of concern over health, agreeable to invasive procedures * Caregiver closely involved with care team
75
How is factitious disorder treated?
* Single provider to coordinate care * Psychotherapy * Tx of comorbid psych disorders * By proxy- must be reported, criminal act, involve social work/protective agencies
76
Condition characterized by intentional faking of s/s to appear ill, impaired, or injured
Malingering
77
How is malingering different from factitious disorder?
* Secondary motivation * Often avoid excessive procedures, especially painful or invasive ones
78
What is the prevalence of malingering?
Unknown * Study found up to 20% patients in pain clinic
79
How is malingering treated?
* Avoid being manipulated by patient for secondary goal * Treat underlying medical conditions ## Footnote Difficult due to patient denial of malingering

Behavioral Dynamics (6 decks)

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