Somatoform Disorders - Exam 3 Flashcards
Up to ____ of primary care patients display at least some degree of somatization.
___ of medical/surgical patients have no known organic cause for their symptoms
25%
10%
What is somatization?
“over response” to symptoms. Subjectively believe themselves to be more ill or disabled than objective evidence would suggest
What are risk factors for somatization? What substance? Describe a typical pt
female
low socioeconomic status
low education
minority
family member with chronic dz
hx of abuse
other psych disorders
unstable, dysfunctional families
alcohol abuse is present
Typically female, unmarried, non-white, poorly educated, and from rural area.
How does the DSM describe “somatoform disorders”?
diseases with physical symptoms not explained by a medical condition
Defined as a syndrome of multiple unexplained physical symptoms
_____ false belief or exaggerated perception that a body part is grotesque or defective
body dysmorphic disorder
multiple unexplained physical symptoms, often accompanied by a sense of urgency
Often have long, complicated medical histories
May have had multiple invasive diagnostic studies / procedures / treatments
May describe themselves as being “sickly” their whole lives
What am I?
What are the common systems affected?
Somatic symptom disorder
GI, reproductive, neuro
Symptoms - pain, N/V/D, bloating, dizziness, dysphagia, SOB
What is the DSM criteria for somatic symptoms disorder?
-1+ symptom that causes distress/disruption of daily life
- excessive thoughts, feelings, or behaviors related to somatic symptom
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
6+ months
What are the specifiers for somatic symptom disorder?
with predominant pain
persistent: severe impairment for longer than 6 months
severity:
Mild - 1 symptom described in criterion B
Moderate - 2+ symptoms described in criterion B
Severe - 2+ symptoms described in criterion B PLUS multiple somatic complaints (or one severe complaint)
What is the tx for somatic symptom disorder?
Best to coordinate care with one PCP
Schedule frequent, routine follow-ups
avoid new or excess diagnostic studies
no specific pharm management
psychotherapy!
_____ is marked by altered voluntary motor or sensory function. What was the previous name? What is the MC age range?
Functional Neurological Symptom Disorder
previously referred to as conversion disorder
women age 10-35
What are some theories of what causes Functional Neurological Symptom Disorder?
-trauma
-comorbid pysch disorders
-lower IQ
-less educated/socially sophisticated
any condition causing delayed verbal communication/impaired ability to articulate distress
-neurologic symptom(s) that do not correlate with the presence of organic neurologic disease
-Often have signs of inconsistency or incongruency
-Hoover’s sign
pseudoseizures, paralysis, blindness, mutism, paresthesia, anesthesia
What am I?
Functional Neurological Symptom Disorder
What is Hoover’s sign?
What is DSM criteria for Functional Neurological Symptom Disorder?
1+ symptoms/deficits affecting voluntary motor or sensory function
Clinical findings are incompatible with recognized neurological or medical condition
cause distress and not better explained by another medical/psych condition
What is the tx for Functional Neurological Symptom Disorder?
symptoms often resolve spontaneously
education about the disorder
therapy referral (insight-oriented or behavioral therapy)
_____ preoccupation with a serious illness (either having or developing it) with minimal to no somatic symptoms to support this concern. What is the older name for it?
Illness anxiety disorder
hypochondriasis
What are the pt factors for illness anxiety disorder?
equal in men and women
age 20-30
Believed patients may have low thresholds of, and tolerance for, physical discomfort
comorbid anxiety disorders
predominant concern over the presence of a major disease
Concerns often start with misinterpretation of benign symptoms
Often have extremely detailed histories
May stay fixed on one disease or move to
a new disease over time
Symptoms may wax/wane with stress
Unswayed by negative objective findings aka refuse to believe it
illness anxiety disorder
What is the DSM criteria for illness anxiety disorder?
Preoccupation with having or acquiring a serious illness
Somatic symptoms are not present
High level of anxiety and easily alarmed about health status
Excessive health related behaviors or maladaptive avoidance
more than 6 months
What is the tx for illness anxiety disorder?
Frequent, regular visits
Compassionate, tactful education on illness
Ordering diagnostic studies only when indicated by objective evidence
Therapy can be helpful, if pts are willing to go
pts often decline psych referral!
medication for comorbid psych disorder
_____ characterized by preoccupations with perceived appearance defects. “imagined ugliness”. What is the alternative name?
Body Dysmorphic Disorder (BDD)
dysmorphophobia
What is the pt population for body dysmorphic disorder?
20-40 men and women
unmarried
related to OCD
strongly associated with social anxiety disorder and MDD
Preoccupation with specific aspects of the patient’s appearance
Believe others notice the “flaw” much more than they do
Almost all will avoid public exposure/interaction
Up to ___ are housebound
up to __ will attempt suicide
What am I?
What are the common problem areas?
Body Dysmorphic Disorder
1/3 housebound
1/5 attempt suicide
facial features, hair, breasts, genitalia
What is the DSM criteria for body dysmorphic disorder?
Preoccupation with 1+ perceived defect / flaw in physical appearance that are not observable or appear slight to others
At some point during disorder, patient performs repetitive behaviors or mental acts due to concern
-Behaviors - mirror checking, excessive grooming, skin picking, reassurance seeking
-Mental acts - comparing appearance to others
Body Dysmorphic Disorder with muscle dysmorphia is ????
idea that muscle mass is too small
What is tx for body dysmorphic disorder?
***“Correction” of perceived flaw (plastic surgery, dental work, etc.) almost never helpful
SSRI: off label but considered first line
Psychotherapy - CBT, cognitive restructuring with exposure therapy
Most patients likely have some degree of physical disease that causes pain, but their response is what determines abnormal illness behavior aka out of proportion pain
Somatic Symptom Disorder with Predominant Pain
What is the MC somatoform disorder? What are the pt related factors?
Somatic Symptom Disorder with Predominant Pain
women
40-50
Possible somatic expression of depression
Possible relation to guilt - “deserving” pain
varying types of pain
Often have long hx of medical and surgical care
May deny any other sources of negative emotion and state if it weren’t for pain, life would be good
Pain may have an associated medical condition, but psych factors are seen to play a major role with the pain
Symptom is not intentionally produced or feigned
What am I?
How long does it have to occur?
Somatic Symptom Disorder with Predominant Pain
pain for more than 6 months (does NOT have to be the same area of the body for the entire 6 months, just pain in general)
What is the tx for Somatic Symptom Disorder with Predominant Pain?
alleviation of underlying psych symptoms and aggravating environmental factors
May have to deal with opiate addiction or dependence
NSAIDs are first line if analgesics are indicated
Avoid opiates; if prescribed - fixed-dose rather than PRN
Psych meds - antidepressants SNRIs TCAs also useful. that have shown benefit in chronic pain may be helpful
______ intentionally faking symptoms to assume “patient” role.
Factitious disorder
What are good guidelines for treatment for somatization disorders?
What is factitious disorder? What is another name for it?
**Characterized by intentional faking of s/s to appear ill, impaired, or injured
**Behavior persists even with no obvious external rewards
**Motivation is to assume the sick role
Munchausen Syndrome
What is Munchausen Syndrome by Proxy?
intentional induction of symptoms on a victim other than the patient with the disorder
aka a person makes someone else sick for the attention
What are risk factors for factitious disorder?
female gender
unmarried
healthcare workers
possible association with childhood abuse
Presentation with psychological or physical signs or symptoms of illness
May have different accounts of illness to different clinicians
Often have been seen at multiple facilities by multiple providers
Misusing medication to induce s/s
Interfering with or contaminating test results
Coach others to provide correlating history to providers
Nonadherence to care plans to aggravate pre-existing illness
Inflicting injuries directly to self
Forging medical records
What am I?
What is the major red flag?
factitious disorder
Often have been seen at multiple facilities by multiple providers
What is the DSM criteria for factitous disorder?
Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
Individual presents themself to others as ill, impaired or injured
Deceptive behavior is evident, even in absence of obvious external rewards
poor wound healing,
pain, seizures, hypoglycemia, GI symptoms, depression, suicidal thoughts
Agree to complex work-ups, specialty consults, and invasive procedures
DO NOT WANT TO SEE PSYCH
few visitors in the hospital
aliases and wandering from one hospital or clinic to another
Classically present to ER on night/weekends
Often have failure to respond to standard treatment
Often become upset or angry when confronted
What am I?
factitious disorder
Historical data is not congruous with objective findings
Illness is often recurrent, unexplained, prolonged, or unusual
Often limited or no response to standard therapy
S/S worsen - when victim is around perpetrator, when victim is
about to be discharged
S/S improve - when victim is not around perpetrator
Caregiver is VERY closely involved with the care team
What am I?
Factitious disorder Imposed on Another
aka mother inflicting symptoms of illness onto child
What is the tx for factitious disorder?
single provider!!
therapy
tx fo comorbid psych disorder
What is malingering? Do pts want excessive work ups?
Characterized by intentional faking of s/s to appear ill, impaired, or injured for a PERSONAL GAIN!!!
Financial gain, medications, legal gain, avoid responsibility
**Often avoid excessive diagnostic and therapeutic procedures, especially painful or invasive ones
