Somatoform Disorders Flashcards
Define MUPS:
Medically unexplained physical symptoms (MUPS)
- Physical symptoms that prompt the suffer to seek health care but remain unexplained after an appropriate evaluation
What are the consequences of MUPS?
- Impaired physician-patient relationship
- Physician frustration
- Patient dissatisfaction
- Psychosocial distress
- Decreased quality of life
- Increased rates of depression and anxiety
- Increased health care utilization
List the types of somatoform disorders:
-
Somatization Disorder
- [Somatic Symptom Disorder]
-
Conversion Disorder
- [Functional Neurologic Symptom Disorder]
-
Pain Disorder
- [eliminated in DSM-V]
-
Hypochondriasis
- [Illness Anxiety Disorder]
-
Body Dysmorphic Disorder
- [now classified as an OCD related disorder]
What are some generalities of somatoform disorders?
- Presence of physical symptoms that suggest a general medical condition, but are not explained by a medical condition
- Psychosocial stress = somatic distress
- Misinterpretation of normal physiological functions
- Not consciously produced or feigned
- Alexithymia
**Somatization Disorder: **
DSM-IV Criteria
- Multiple recurring physical complaints that begin before age 30
-
All 4 of the following criteria at some point:
- 4 pain symptoms
- 2 non-pain GI symptoms
- 1 sexual complaint
- 1 pseudoneurological complaint
- Not caused by known medical condition
- Not intentionally produced
[Somatic Symptom Disorder]:
[DSM-V Criteria]
- 1+ somatic symptom that are distressing or result in significant disruption of daily life
- Excessive thoughts, feeling, or behaviors related to the somatic symptoms or associated health concerns as manifested by:
- Disproportionate and persistent thoughts about seriousness of symptoms
- Persistently high level of anxiety about health
- Excessive time and energy devoted to these symptoms
- State of being symptomatic is persistent (typically greater than 6 months)
Somatization Disorder:
Epidemiology
-
Somatization disorder
- General population: 0.01%
- Primary care setting: 3%
-
Subsyndromal somatization disorder
- General population: 11%
- Primary care setting: 20%
- Patients typically found in general medical setting
- RARELY seek psychiatric care
- Often refuse psychiatric care due to belief that symptoms are related to undiagnosed primary medical condition
Somatization Disorder:
Clinical Features
- Patients describe themselves as “sickly”
- Medical histories are circumstantial, vague, inconsistent and disorganized
- Describe complaints in dramatic, exaggerated fashion
- Large number of outpatient visits
- Frequent hospitalizations
- Repetitive subspecialty referrals
- Large number of diagnoses
- Multiple medications
Somatization Disorder:
Differential Diagnosis
-
Primary Medical Disorders!
- Disorders with transient nonspecific symptoms
- Examples: MS, MG, SLE, AIDS, AIP, endocrine disorders
- Disorders with transient nonspecific symptoms
-
Psychiatric conditions:
- Other somatoform disorders
- Depression
- Anxiety
The 3 features that most suggest a diagnosis of somatization disorder instead of another medical disorder are…
- Involvement of multiple organ systems
- Early onset and chronic course without development of physical signs or structural abnormalities
- Absence of laboratory abnormalities that are characteristic of the suggested medical condition
Somatization Disorder:
Treatment Issues
- Schedule regular follow-up visits
- Perform a brief physical exam focused on the area of discomfort on each visit
- Look closely for objective signs of disease rather than taking the patient’s symptoms at “face value”
- Avoid unnecessary tests, invasive treatments, referrals and hospitalizations.
- Avoid insulting explanations such as “the symptoms are all in your head”
- Explain that stress can cause physical symptoms
- Set limits on contacts outside of scheduled visits
How can psychotherapy be used to treat somatization disorder?
- Not responsive to long-term insight oriented psychotherapy
- Short-term dynamic therapy has shown some efficacy
- Cognitive-behavioral therapy has been shown to be effective
How is psychopharmacology used to treat somatization disorder?
- Antidepressants have shown inconsistent results
- Antidepressants have limitations in treating somatization disorder
- Partial response instead of remission
- Higher discontinuation rates
- Sensitive to side effects
- Attribution to physical, whereas antidepressants suggest psychiatric
- Unknown long-term efficacy
Conversion Disorder [Functional Neurological Symptom Disorder]
- Definition:
- Clinical Findings:
- Epidemiology:
-
1 + symptom affecting voluntary motor or sensory symptoms, suggesting neurological disorder, proceeded by acute, identifiable stressor
- [no longer needs to be proceeded by acute stressor]
- Clinical findings incompatible with symptom presentation and recognized medical or neurologic illness
- 1/3 patients have true neurological illness
- 25% recur within the first year
What are the clinical features of conversion disorder?
- “la belle indifference”
- Symptoms likely to occur following stress
- Symptoms tend to conform to patients understanding of neurology
- Inconsistent physical exam
Conversion Disorder:
Treatment
-
Conservative treatment
- Reassurance
- Physical and occupation therapy
- Psychotherapies
-
Amytal interview, hypnosis
- If the symptom can be resolved by these modalities, they are probably the result of a conversion disorder
What are the prognostic factors for conversion disorder?
-
Good prognosis:
- Onset following a clear stressor
- Prompt treatment
- Symptoms or paralysis, aphonia and blindness
-
Poor prognosis:
- Delayed treatment
- Symptoms of seizures or tremor
Pain Disorder:
DSM-IV Criteria
- Pain in 1+ anatomical sites is the predominant focus of clinical attention of is of significant severity to warrant clinical attention
- Complaints of pain are significantly affected by psychological factors
-
Psychological factors are required in the…
- Genesis of the pain
- Severity of the pain
- Maintenance of the pain
- Pain is not intentionally produced or feigned
Hypochondriasis [Illness Anxiety Disorder]:
DSM-IV [V] Criteria
- Preoccupation with fears of having a serious illness that does not respond to reassurance after appropriate medical work-up.
- Belief not of delusional intensity and is not restricted to concern about appearance
- Duration of at least 6 months
- [Somatic symptoms typically not present; if present, only mild in intensity]
- [High level of anxiety about health and easily alarmed about personal health status]
Hypochondriasis:
Clinical Features
- Bodily preoccupation
- Disease phobia
- Disease conviction
- Onset in early adulthood
- Chronic with waxing and waning of symptoms
Hypochondriasis:
Treatment
-
General aspects
- Establishment of trust
- History taking
- Identification of stressors
- Education
- Cognitive-behavioral therapy
- Supportive therapy
-
Pharmacotherapy
- Serotonergic meds appear to most beneficial
Body Dysmorphic Disorder [OCD anxiety disorder]:
DSM-IV [V] Criteria
- Pervasive feeling of ugliness of some aspect of their appearance despite a normal or nearly normal appearance
- If slight physical anomaly is present, person’s concern is markedly excessive
- [Repetitive behaviors or mental acts in response to appearance concerns]
- Epidemiology; unknown in general population
- Dermatologic setting: 12%
- Cosmetic surgery setting: 6-15%
Body Dysmorphic Disorder:
Clinical Features
- Onset between 15 and 30 years old
-
Appearance preoccupation
- Any body part
- Most often involve the face or head
- Typically think about flaws 3-8 hours/day
-
Compulsive behaviors
- Intent to examine, improve, seek reassurance or hide perceived defect
What are the comorbidities for body dysmorphic disorder?
- Major depression: 60-80%
-
Personality disorders: 57-100%
- Avoidant PD is most common
- Social phobia: 38%
- Substance use: 36%
- Obsessive compulsive disorder: 30%
Body Dysmorphic Disorder:
Treatment
- Avoid iatrogenic harm!
- Cognitive-behavioral therapy
-
Pharmacotherapy
- Serotonin-specific medications
- May reduce symptoms in ~50% patients
- High-dose and delayed response (10-12 weeks)
- Serotonin-specific medications
-
“Corrective” surgery does NOT work
- Potential cause of litigation
- How do deception syndromes differ from somtaform disorders?
- What are methods of inducing illness?
- What are the deception syndromes?
- Differ from somatoform disorders in that signs and symptoms are INTENTIONALLY PRODUCED
-
Methods of inducing illness
- Exaggerations
- Lies
- Tampering with tests to produce positive results
- Manipulations that cause actual physical harm
-
Syndromes
- Factious disorder
- Malingering
Factitious Disorder:
DSM-IV Criteria
- Intentionally exaggerates or induces signs and symptoms of illness
- Motivation is to assume the sick role
- External incentives for the illness inducing behavior are absent
Describe the epidemiology of factitious disorder:
- Prevalence in general population is unknown
- Diagnosed in about 1% of patients seen in psychiatric consultation in general hospitals
- Likely higher in referral centers
What is the etiology of factitios disorder?
- Little data is available since these patient resist psychiatric intervention
- Many patients suffered childhood abuse resulting in frequent hospitalizations
- Hospitals viewed as safe
- Self-enhancement model
- Factitious disorder may be a means of increasing or protecting self-esteem
What are the 3 different types of factitious disorders?
-
Munchausen syndrome
- 10% of factitious disorder patients
- Severe and chronic factitious disorder
- Pseudologia fantastica
-
Factitious disorder by proxy
- A person intentionally produces physical signs or symptoms in another person under the first person’s care
-
Ganser’s syndrome
- Characterized by the use of approximate answers
What is the differential diagnosis for factitious disorders?
- Must establish the intentional and conscious production of symptoms
- Direct evidence
- Excluding other causes
- True physical illness
- Other somatoform disorders
- Malingering
What are the predisposing factors for factitious disorders?
- True physical disorders in childhood leading to extensive medical treatment
- Employment (present or past) as a medical paraprofessional
- Severe personality disorder
- Borderline personality disorder is the most prevalent
How is factitious disorder managed?
- No specific treatment shown effective
- Early identification
- Prevent iatrogenesis
- Beware of negative countertransference
- Be mindful of legal and ethical issues
- Address any psychiatric diagnosis underlying the factitious disorder diagnosis
- Rarely allowed by the patient
Define malingering:
- The intentional production of feigning illness
-
Motivated by external incentives:
- drugs, litigation, financial compensation, avoidance of work/military, evade criminal prosecution
When should malingering be strongly considered?
Consider strongly if:
- Medicolegal presentation
- Marked discrepancy between person’s claimed stress/disability and objective findings
- Lack of cooperation with evaluation and treatment
- Antisocial personality disorder