Trans 065: Somatic Symptom and Related Disorder Flashcards
malingering vs factitious disorder?
Malingering - goal is for material or concrete gain
factitious disorder - goal is to assume the patient role
If it’s UNCONSCIOUS AND UNINTENTIONAL it is more of
somatic symptom disorder.
- Deep seated neurosis that produces bodily symptoms
- Culturally sanctioned
- Index of a disease or disorder, indication of psychopathology
- Leads to functional impairment, disability days, use of health care services
SOMATIZATION AS DIMENSION OF DISTRESS
Tendency to experience somatic sensations as intense, noxious or disturbing.
somatosensory amplification
3 elements of somatosensory amplification?
o Hypervigilance to bodily sensations
o Predisposition to select out and concentrate on weak or infrequent bodily sensations
o Reaction to sensations with cognitions and affect that intensify them to make them more alarming
Parang when they feel that there’s something wrong with their body it’s like a big problem agad that needs to be addressed.
illness vs disease?
• Illness – response of the individual and his/her family to symptoms
• Disease – defined by the physician, associated with pathophysiological processes and documentable lesions
Some people say “hay, sama ng pakiramdam ko, I don’t feel well”, then that is illness.
Once it’s diagnosed, there’s lab result to back it up, then it becomes a disease.
• May have a genetic component
• Developmental Factors:
o Roots in early family experience where physical symptoms are a major form of interpersonal communication
o Childhood exposure to parental chronic illness or abnormal illness behavior increases risk of somatization in later life
o Children with poor awareness of emotional experiences are more likely to experience unexplained somatic symptoms
o Anxious attachment behavior
these etiology may indicate what disesase?
Somatoform disorder
• Cognitive Theories:
o Cognitive distortion
• Personality Characteristics:
o Introspectiveness (tendency to think about oneself)
o Negative affectivity (negative mood, poor self-concept, pessimism)
• Psychodynamic Factors:
o Bodily symptoms interpreted as metaphors through which a patient expresses emotional distress or psychic conflict
o Bodily preoccupations as attempt to restore a sense of integration
these charachteristics are associated with what disorder?
Somatoform disorder
• Physical and Sexual Abuse:
o Poorly understood mechanism of association
o Sexual abuse negatively affects “embodiment” (experience of the self in and through the body)
o Tendency towards dissociation – increased physical symptoms
• Sociocultural Factors:
o Ubiquitous across cultures
• Iatrogenesis:
o Health care insurance and disability systems may foster somatization by providing reinforcement
o Unnecessary diagnostic testing and treatments by well intentioned but uninformed actions of physicians
these characteristics are associated with what disorder?
somatoform disorder
some physiological mechanisms of somatization?
autonomic arousal muscle tension Hypervent Vascular changes cerebral information processing physiological effects of inactivity sleep disturbance Brain cytokines
- At least 6 or more months of a general and non delusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms
- Belief persists despite negative lab tests, benign course of disease over time, and reassurances of the doctors
Somatic Symptom Disorder (hypochondriasis)
what disorder?
• Prevalence: 4-6%, M=F, 20-30 years old
o Happens in 3% of medical students, usually in the first 2 years, but generally transient
o 80% may have existing depressive or anxiety disorder
o Multiple consults with doctors, misuse of healthcare system
o Develop in the context of a stressful life event involving death or illness.’
SOMATIC SYMPTOM DISORDER (hypochondriasis)
• Develop in the context of a stressful life event involving death or illness
• Disproportionate incidence of disease in the family
o Strong memories of illness that could become the focus of anxiety
these are etiology of what disorder?
Somatic Symptom Disorder (hypochondriasis)
Social Learning
• Symptoms are viewed as request for admission to the sick role made by a person facing seemingly insurmountable problems, used to avoid and escape obligations
This is unconscious. Hindi sya deliberately thought by the patient.
• Getting attention if sick
Somatic Symptom Disorder (hypochondriasis)
Psychodynamic
• Aggressive and hostile wishes toward others are transferred into physical complaints
• Defense against guilt, a sense of innate badness, expression of low self-esteem and a sign of excessive self-concern
• Pain and suffering as means of atonement and undoing, and as deserved punishment for wrongdoing and sense of wickedness and sinfulness
Somatic Symptom Disorder (hypochondriasis)
Genetics
• Linked to antisocial personality disorder
o Neurologically based disinhibition characterised by impulsive behaviour
o Short term gains at the expense of long-term problems
• Runs in families
Somatic Symptom Disorder (hypochondriasis)
Course and prognosis of Somatic Symptom Disorder (hypochondriasis)
• Episodic, lasts from months to years
• Somatic symptoms associated with psychosocial stressors
• Good prognosis is associated with:
o High socioeconomic status
o Treatment-responsive anxiety or depression
o Sudden onset of symptoms
o Absence of a personality disorder
o Absence of a related non psychiatric medical condition
treatment of somatic symptom disorder?
• Usually resisted by patient, unless done in a medical setting with focus on stress reduction and education in coping with chronic illness
• Scheduled physical examination to reassure the patient that physicians are not abandoning them and that their complaints are taken seriously
• Pharmacotherapy to relieve other underlying drug-responsive condition (anxiety or depression)
• Individual therapy (insight oriented therapy, behavior therapy, cognitive therapy)
• CBT
o Identification and challenging illness-related misinterpretation of symptoms
o Coaching to seek less reassurance regarding their concerns
- Known as PAIN DISORDER in DSM IV TR
- Presence of, or focus on, pain in one or more body sites and is sufficiently severe to come to clinical attention
- Psychological factors are necessary in the genesis, severity or maintenance of the pain, which causes significant distress, impairment, or both
SOMATIC SYMPTOM DISORDER WITH PREDOMINANT PAIN
• Post-traumatic, neuropathic, neurological, iatrogenic, musculoskeletal
Marami nito mga vehicular accident tapos meron silang mga fracture sa spine or may kailangan ireplace yung hip, mga ganun or they need prosthesis.
Yun bang mga surgical cases. Ex. Sa abdomen may adhesions but the level of adhesion naman is not enough or na-adhesiolysis na pero meron paring pain.
• Associated with anxiety disorder, depressive disorder, and alcohol dependence
these are diagnosis and clinical feature of
SOMATIC SYMPTOM DISORDER WITH PREDOMINANT PAIN
Psychodynamic Factors
• Way to express intrapsychic conflict and articulate internal feeling states
• Atonement for perceived sin, expiation of guilt, suppressed aggression, convinced that they deserve to suffer
• Way to obtain love
Behavioral Factors
• Pain may become intense when followed by attention/monetary gain or avoidance of distasteful activities
etiology of which disorder?
SOMATIC SYMPTOM DISORDER WITH PREDOMINANT PAIN
Interpersonal Factors
• To manipulate and gain advantage in interpersonal relationships, ensure devotion of a family member, or to stabilize a fragile marriage
Biological Factors
• Serotonin and endorphin can modulate pain
For ortho, mga old ortho nakikita ko, they give tricyclic anti-depressants to help manage chronic pain. Yung iba naman they give serotonin, norepinephrine reuptake inhibitors like duloxetine or desvenlafaxine which we give to help modulate pain.
etiology of what disorder
SOMATIC SYMPTOM DISORDER WITH PREDOMINANT PAIN
treatment for SOMATIC SYMPTOM DISORDER WITH PREDOMINANT PAIN
• Because it may not be possible to reduce or completely eliminate pain, treatment should focus on REHABILITATION
Rehab helps build the muscles, tendons, tissues, bones. The person overall feels stronger.
• Identify psychological factors
• Pharmacotherapy: Antidepressants (SSRI’s, SNRIs, TCA’s) more than analgesics
• Psychotherapy: Cognitive re-structuring
- Similar etiology to Somatic Symptom Disorder
- Nature of a patient’s relationship to a significant other in his life may be significant (eg., father died of a heart attack)
etiology of what disease?
illness anxiety disorder
• An illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggests another medical condition, but that is judged to be caused by psychological factors, because the illness is preceded by conflicts or other stressors
o Symptoms often precipitated by marked stress, which often takes the form of a physical injury
• Symptoms are not intentionally produced, not caused by substance use, and excludes symptoms of pain and sexual dysfunction
• The gain is primarily psychological, and not social, monetary or legal
FUNCTIONAL NEUROLOGIC SYMPTOM DISORDER (CONVERSION DISORDER)
epidem of conversion disorder?
- 11 to 300 of 100,000
- 2:1 F:M
- Thorough medical and neurologic workup is essential
(3) are the most common conversion disorder symptoms
Paralysis, blindness and mutism are the most common conversion disorder symptoms
primary gain vs secondary gain vs la belle indifference, identification?
• Primary gain - internal conflicts are kept outside of their awareness
• Secondary gain - tangible advantages as a result of being sick (e.g. excused from obligations, receive support, control other person’s behavior)
• La Belle Indiferrence - inappropriately cavalier attitude toward serious symptoms
parang wala lang, di sila makalakad okay lang. Nagsiseizure sila wala lang
• Identification - unconsciously modeling symptoms of someone who important to them
etiology of what disorder?
Psychodynamic
• Caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom
• Conflict between an instinctual impulse (E.g. aggression or sexuality) and prohibitions against its expression
Learning Theory
• classically conditioned learned behaviors as a means of coping with otherwise impossible situations
Biological Factors
• Hypometabolism of the dominant hemisphere, hyper metabolism of the non dominant hemisphere and impaired hemispheric communication
• Excessive cortical arousal that inhibit patient’s awareness of bodily sensations
FUNCTIONAL NEUROLOGIC SYMPTOM DISORDER (CONVERSION DISORDER)
Treatment for FUNCTIONAL NEUROLOGIC SYMPTOM DISORDER (CONVERSION DISORDER)
• Pharmacotherapy
• Psychotherapy
o Insight-oriented supportive or behavior therapy ‣ Identify and attend to the traumatic or stressful life event
o Reduction of any reinforcing or supportive consequences of the conversion symptom (e.g. secondary gain)
o Good relationship with the psychotherapist, focus on stress and coping
They cannot let it out; it’s their way of releasing the internal conflict. Focusing in stress and coping, being able to identify stressors. Overall, that might help.
PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITIONS (how to say that this is psychological factors)
• Based on 2 assumptions:
o Unity of the mind and body
o Psychological factors must be taken into account when considering all disease states
• Medical condition must always be present for the diagnosis to be made
- Patients simulate, induce or aggravate illness to receive medical attention, regardless of whether or not they are ill
- Inflict painful, deforming or life-threatening injury on themselves, their children or other dependents
- Motivation is simply to receive medical care and to partake in the medical system
what disorder?
FACTITIOUS DISORDER
refer to a syndrome, in which patients embellish their personal history, chronically fabricate symptoms to gain hospital admission, and move from hospital to hospital.
Gusto lang nila to be in the medical system
“Munchausen syndrome”
Halimbawa mother gusto nya madala anak sa ospital. She’ll do something sa anak nya para magkasakit. Perpetrator (mother) receives the diagnosis.
FACTITIOUS DISORDER IMPOSED ON ANOTHER (PREVIOUSLE FACTITIOUS DISORDER BY PROXY)
• 0.8 to 1% of psychiatric consultations
• Usually white, middle-aged, unemployed, unmarried, and without significant and social or family attachments
Kasi ung the care from the healthcare team, yun yung parang gusto nya
• Normal or above-average intelligence, absence of formal thought disorder
FACTITIOUS DISORDER IMPOSED ON ANOTHER (PREVIOUSLE FACTITIOUS DISORDER BY PROXY)
• 0.8 to 1% of psychiatric consultations
• Usually white, middle-aged, unemployed, unmarried, and without significant and social or family attachments
Kasi ung the care from the healthcare team, yun yung parang gusto nya
• Normal or above-average intelligence, absence of formal thought disorder
FACTITIOUS DISORDER IMPOSED ON ANOTHER (PREVIOUSLE FACTITIOUS DISORDER BY PROXY)
• Poorly understood, history of parents as rejecting figures
• Illness is used to re-create the desired positive parent-child bond
• Masochistic personality make-up (those who seek surgical and invasive procedures)
gagawin nila yun sa sarili nila
etiology of waht disease?
FACTITIOUS DISORDER IMPOSED ON ANOTHER (PREVIOUSLE FACTITIOUS DISORDER BY PROXY)
• Unusual, dramatic presentation of symptoms that defy conventional medical or psychiatric understanding
• Symptoms do not respond appropriately to usual treatment or medications
Kasi they can self-sabotage dba?
• Emergence of new, unusual symptoms when other symptoms resolve
• Reluctance to give access to collateral sources of information
• Extensive medical history or multiple surgeries; multiple drug allergies; medical profession
• Few visitors
Doctors cannot have access to relative. Kasi the relative can say “ay hindi ganyan yan”
• Ability to forecast progression of symptoms or treatment
these are clues that should trigger suspicion of?
FACTITIOUS DISORDER IMPOSED ON ANOTHER (PREVIOUSLE FACTITIOUS DISORDER BY PROXY)
GUIDELINES OF MANAGEMENT AND TREATMENT OF FACTITIOUS DISORDER IMPOSED ON ANOTHER (PREVIOUSLE FACTITIOUS DISORDER BY PROXY)
• Active pursuit of a prompt diagnosis
• Regular interdisciplinary meetings to reduce conflict and splitting among staff. Manage staff countertransference
• Avoid aggressive direct confrontation
• Treat underlying psychiatric disturbances
• Appoint primary care provider
• Consider prosecution for fraud, as behavioral disincentive
Not in the Philippines
what approach to the management of somatic symptom disorder
o Help patient to link his/her physical symptoms with psychological or stressful factors in his or her life
pag stressed po kayo lumalabas yung ganitong symptoms
Re attribution approach
what approach to the management of somatic symptom disorder
Develop a close and trusting relationship with the patient
• Psychotherapeutic approach
what approach to the management of somatic symptom disorder
o For hostile patients who deny the importance of psychological factors or social factors in their symptoms, treats patient as though he or she has a physical problem, and interventions are framed in a medical model
So here’s talk about receptos, chemical imbalance if they don’t see there’s psychologic problems
• Directive approach
Approach to the patient with somatic symptom syndrome
o Explain to the patient that his/her conversion symptoms are not caused by a serious disease
o Provide some form of “face saving” mechanism for symptom resolution
o Choice of words is very important
▪ “Stress related seizures” or “functional seizures” instead of “pseudoseizures or psychogenic seizures
