Somatoform Disorders Flashcards
Somatization
- somatic expression of psychological distress
- the idea that the body can express psychological distress through manifestations of the body
Somatic Symptom Disorders
- 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
Fictitious Disorder
-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
Malingering
-intentional production of false or grossly exaggerated physical or psychological symptoms for EXTERNAL INCENTIVES
E.g. Prescriptions, time off work, workers comp., disability
Classification of Somatic Symptom and Factitious Disorders
DSM IV: Axis I
DSM 5: Section 1
DMS IV (Review of Axes)
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).
DSM 5
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
DSM IV to 5 Transition
-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
DSM IV: dysthymic Disorder
Persistent depressive disorder
DSM IV: Somatization Disorder
Somatic symptom disorder, severe
DSM IV: Pain disorder
Somatic symptom disorder with predominant pain
DSM IV: Asperger’s Disorder
Autism spectrum Disorder
DSM IV: Depersonalization Disorder
Depersonalization/derealization disorder
DSM IV: Vaginismus
Genito-Pelvic pain/penetration disorder
DSM IV: Dyspareunia
Genito-pelvic pain/penetration disorder
Somatic Symptom Disorder (Diagnostic Criteria)
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.
Tx of Somatic Symptom Disorder VERY IMPORTANT
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
Why is this such an Issue?
-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
Conversion Disorder (diagnostic criteria)
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
Tx of Conversion Disorder
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
Somatic Symptom Disorder with Predominant Pain (diagnostic criteria)
- 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 - Epidemiology
- A: psychological factors affect up to 40% of pain patients
- B: women are affected twice as often as men
Tx of Pain Disorder
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
Illness Anxiety Disorder (diagnostic criteria)
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
Tx for Illness Anxiety Disorder
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
