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BMB Lectures > Somatoform Disorders > Flashcards

Somatoform Disorders Flashcards

1
Q

Somatization

A
  • somatic expression of psychological distress

- the idea that the body can express psychological distress through manifestations of the body

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2
Q

Somatic Symptom Disorders

A
  • psychiatric disorders characterized by physical symptoms (not fully explained by another general medical condition) that are NOT INTENTIONALLY PRODUCED (KEY, this isn’t lying)
  • This is perceived and it’s real. The pain/distress is real. It’s perceived in the body and is hard to distinguish between medical and psychiatrically signs and symptoms
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3
Q

Fictitious Disorder

A

-psychiatric disorders in which physical or psychological symptoms are intentionally produced or feigned in order to assume the sick role

  • these are different. They’re a set of disorders in which physical/psychological symptoms are intentionally produced
  • they present this on purpose
  • difference between this and malingering is the sick role. Malingering is “I want a free kick” or “My stomach hurts and I don’t want to go to school”
  • THIS is getting the attention that becomes with being a patient
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4
Q

Malingering

A

-intentional production of false or grossly exaggerated physical or psychological symptoms for EXTERNAL INCENTIVES

E.g. Prescriptions, time off work, workers comp., disability

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5
Q

Classification of Somatic Symptom and Factitious Disorders

A

DSM IV: Axis I

DSM 5: Section 1

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6
Q

DMS IV (Review of Axes)

A

Axis I: Psychiatric illnesses
Axis II: Personality Disorders and Developmental Delays
Axis III: Other Medical Illnesses
Axis IV: Psychosocial and ENV factors
Axis V: Global Assessment of Function (1-100)

Typically have meds and Tx’s for Axis 1. Generally don’t have these for Axis II (obviously there are exceptions).
Axis IV: things that make patient more or less willing to engage in treatment (motivation for Tx).

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7
Q

DSM 5

A

Axis I-III now Section 1

  • combined attention to clinical disorders, including personality disorders and intellectual disabilities
  • other conditions that are the focus of treatment
  • other med conditions

Axis IV: Section 2

  • reason for visit
  • psychosocial and contextual factors
  • expanding list of V and Z codes: really sort of a billing thing. They’re basically items that don’t appear on the axes

Axis V: now Section 3
-disability included in notation
-WHO Disability Assessment Schedule 2.0 included as option
Little write put here. You can have a paragraph or 2 about a patient’s particular presentation

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8
Q

DSM IV to 5 Transition

A

-all but 14 of the -200 DSM 5 diagnostic terms are essentially the same as, or identical to, the -200 DSM IV terms
-there are 14 noteworthy term transitions from DSM IV to 5.
Gradually you should learn and use these paired terms synonymously, for this course, exams and conversations
-In half the cases, the transition is from a stigmatizing, judgmental DSM-IV term to a less judgmental DMS 5 term
-just as you automatically link (I think) hepatocellular degeneration and Wilson’s Disease, you should easily make the following links:

Changes designed to reduce stigma:

  • mental retardation——intellectual disability (intellectual developmental disorder)
  • dementia—–major neurocogntive disorder
  • Gender identity disorder—–Gender dysphoria
  • Substance (e.g. Alcohol, cocaine) abuse—–substance use disorder
  • Substance dependence—–substance use disorder
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9
Q

DSM IV: dysthymic Disorder

A

Persistent depressive disorder

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10
Q

DSM IV: Somatization Disorder

A

Somatic symptom disorder, severe

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11
Q

DSM IV: Pain disorder

A

Somatic symptom disorder with predominant pain

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12
Q

DSM IV: Asperger’s Disorder

A

Autism spectrum Disorder

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13
Q

DSM IV: Depersonalization Disorder

A

Depersonalization/derealization disorder

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14
Q

DSM IV: Vaginismus

A

Genito-Pelvic pain/penetration disorder

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15
Q

DSM IV: Dyspareunia

A

Genito-pelvic pain/penetration disorder

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16
Q

Somatic Symptom Disorder (Diagnostic Criteria)

A

Epidemiology: lifetime prevalence of 0.4%
Female to male ratio: 20:1
5-10% of primary care ambulatory patients

A: on roe more somatic symptoms that are distressing or result in significant disruption of daily life
B: excessive thoughts, feelings or behaviors related to the somatic symptoms associated health concerns as manifested by at 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
C: although any one somatic symptom may not be continuously present the state of being symptomatic is persistent (typically more than 6 months)
Specifiers: with predominant pain
Specify If: persistent
Specific if: mild (1 criterion from B), moderate (2+ criteria B) or severe (2+ Criteria B and mult. Somatic complaints [or one very severe somatic symptom])

Comorbidity with the symptoms is the norm. Anxiety is common and co-morbid mood.

17
Q

Tx of Somatic Symptom Disorder VERY IMPORTANT

A

a: Management in primary care settings:
1. Develop and maintain therapeutic alliance (you want to communicate to patients the foundational aspects that you and they must comprehend)
2. base diagnostic procedures and therapeutic interventions on objective findings (physical exams and labs are very important. NEED to rule out other medical conditions)
3. Maintain regular appointment schedule (may come in every 3-6 months pending on severity of symptoms
4. Redefine treatment goal as management rather than a cure
5. EDUCATE THEM ABOUT MIND-BODY CONNECTION and ENCOURAGE PSYCHIATRIC CONSULTATION

b. Psychiatric Tx
1. Diagnose and treat co-morbid depressive and anxiety disorders
2. Supportive psychotherapy (focus on strengths) to improve direct expression of emotion distress and CBT (how our minds affect our behaviors) to correct dysfunctional attitudes and encourage activities that have been avoided

18
Q

Why is this such an Issue?

A

-among other reasons: stigma of psychiatric symptoms vs. relative acceptance of “medical” problems

  • people think you’re crazy, makes people uncomfortable
  • may be that you have these psychological illnesses and they manifestation in acceptable ways like back pain, etc. It’s more subconscious. Socially acceptable expression of unsocial acceptable symptoms
19
Q

Conversion Disorder (diagnostic criteria)

A

A: one or more symptoms of altered voluntary motor or sensory function
B: clinical findings provide evidence of incompatibility between the symptom and recognized neurological or med conditions
C: the symptom or deficit is not better explained by another medical or mental disorder
D: the symptom or deficit causes clinical significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation

Specify symptom type:
-with weakness or paralysis
-with abnormal movement (tremor, dystopia movement, myoclonus, gait disorder)
-with swallowing symptoms
-with speech symptoms
-with attacks or seizures
-with anesthesia or sensory loss
-with special sensory symptoms
-with mixed symptoms
Specify if: acute episode vs. Persisitent
Specify if: with or without psychological stressor

20
Q

Tx of Conversion Disorder

A

A: supportive psychotherapy focusing on stress, copping and direct expression of emotional distress
B: suggestive therapy for symptom removal, especially in acute Conversion Disorders
C: Chronic Conversion Disorder requires treatment like that described for Somatization Disorder/Somatic Symptom Disorder

21
Q

Somatic Symptom Disorder with Predominant Pain (diagnostic criteria)

A
  1. Criteria
    - A: pain of sufficient severity to require assessment
    - B: pain causes significant functional impairment or distress
    - C: PSYCHOLOGICAL FACTORS have a role in onset, severity, exacerbation or maintenance of the pain
    - D: pain is NOT INTENTIONALLY PRODUCED OR FEIGNED
    - E: pain is not a component of another psychiatric disorder or sexual dysfunction
  2. Epidemiology
    - A: psychological factors affect up to 40% of pain patients
    - B: women are affected twice as often as men
22
Q

Tx of Pain Disorder

A

A: Tx for chronic pain as outlined for Somatization Disorder
B: antidepressants (e.g. Tricyclics antidepressants, duloxetine)
C: psychotherapy using cognitive behavioral therapies including biofeedback and relaxation training

23
Q

Illness Anxiety Disorder (diagnostic criteria)

A

A: Preoccupation with having or acquiring a serious illness
B: somatic symptoms rate not present or, if present, or only mild in intensity. If another med condition is present or there’s a high risk for developing a med condition (e.g. Strong family Hx present), the preoccupation is clearly excessive or disproportionate
C: There’s a high level of anxiety about health, and the individual is easily alarmed about personal health status
D: the individual performs excessive health-related behaviors (repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g. Avoids doctors appointments or hospitals)
E: illness preoccupation has been persistent for at least 6 months, but the specific illness that’s feared may change over that period of time
F: the illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, OCD, or delusional disorder (Somatic type)
Specify whether: care-seeking type or care-avoiding type

24
Q

Tx for Illness Anxiety Disorder

A

A: Tx as outlined for Somatization Disorder/Somatic Symptom Disorder
B: SSRIs effective in reducing preoccupations as there is often comorbid anxiety and/or depression

25
Q

Body Dysmorphic Disorder (now under Obsessive Compulsive and Related Disorders)

A

A: preoccupation with one or more perceived defects or flaws and physical appearance that are not observable or appear slight to others
B: at some point during the course of the disorder, the individual has performed repetitive behaviors or mental acts in response to appearance concerns
C: patient causes Lin ally significant distress or impairment in social, occupational or other important areas of functioning
D: the patient’s preoccupation is not better explained by concerns with body fat or weight in an individual’s is symptoms need diagnostic criteria for an eating disorder here
Specify if: with muscle dysphoria-the individual is preoccupied with the idea that his/her body build is too small or insufficient muscular. The specifier is used even if the individual is preoccupied with other body areas, which is often the case
Specify if: with good or fair insight- the individual reconfigures that the body dysmorphic disorder beliefs are definitely or probably not true or that they may nor may not be true
Specify if: with poor insight: individual thinks that the body dysmorphic disorder beliefs are probably true
Specify if: with absent insight/delusional beliefs-individual is completely convinced that the body dysmorphic disorder beliefs are true

26
Q

Tx of Body Dysmorphic Disorder

A
  • SSRIs are effective in reducing preoccupations

- CBT

27
Q

Fictitious Disorder (Dx criteria)

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 if: single episode or recurrent

28
Q

Tx for Factitious Disorder

A
  1. Tx as outlined for somatization disorder
  2. Confrontation of the factitious nature of the illness is not always appropriate in all cases. Most patients respond to a redefinition of the illness behavior
  3. Prognosis is better in patients with underlying depression (because you scan treat this), less severe personality disorders, stable social support systems, and ability to maintain rapport with treating physicians
29
Q

Fictitious Disorders and Factitious Disorder Imposed on Another (characteristics)

A

Peregrinations: the doctor shop. Constant movement. On to the next PCP after they don’t like the diagnosis

Extreme/dramatic Deception: scan see some real fictional stories built

Recurrent Episodes

30
Q

Malingering

A

A: the intentional production of illness or grossly exaggerated physical or psychological symptoms that is motivated by external incentives such as avoiding military duty, obtaining financial compensation, evading criminal prosecution or obtaining drugs

Management:

1: should be confronted in a firm but empathic manner that leaves an opportunity for constructive dialogue and appreciation for any psychiatric problems (e.g. Substance dependence)
2: neuropsychological testing: SIRS (structured interview of reported symptoms)

31
Q

Dissociative Disorders

A

Dissociative Identity Disorder
Dissociative Amnesia
Depersonalization/Derealization Disorder
Other specified Dissociative Disorder
Chronic and recurrent syndromes of mixed dissociative symptoms
Identity disturbance d/t prolonged and intense coercive persuasion
Acute dissociative reactions to stressful events
Dissociative trance

Dissociation: in a response to trauma or abuse or neglect. It’s a defense mechanism. if you’re chronically abused over childhood, esp. by a caregiver, that can be disturbing for a child. These people are hurting me, what’s wrong with me that they’re doing this to me? (Subconscious process). One way the mind can protect itself is to check out of reality (dissociate)

32
Q

Animal Model For Dissociative Disorders

A

The concept of dissociation as a response to trauma is derived in part from an animal model of defensive response to live-threatening stress, such as an attack by a predator. Under such circumstances, animals have displayed:
Freezing/tonic immobility
Passivity
Hyperarousal
Analgesia
All of these have analogies in human dissociative symptoms
If it’s a conscious process, it’s not a dissociative disorder. They develop these personalities. different personalities can arise to help with protection from abuse/trauma

33
Q

Defense Mechanisms

A

Level I: pathological defenses: delusional projection, splitting
(They’re out to get me, but not as severe as paranoia)
Level II: immature defenses: fantasy, projection, passive aggression, acting out
(Somatization would possibly be put here)
Level III: neurotic defenses: intellectualization, reaction formation, dissociation
(Not necessarily more mature than level 2, neurotic meaning unusual)
Level IV: mature (humor, sublimation, altruism, anticipation)

BMB Lectures (14 decks)

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