Trastornos por sintomas somaticos Flashcards
12.1.
Which of the following DSM-5 criteria are no longer required
for a diagnosis of a somatic disorder?
A. Abnormal labs and medical findings
B. Anxiety and depressive symptoms
C. Impairment daily
D. Persistent belief of an undetected disease
E. Symptoms that cannot be medically explained
12.1. E. Symptoms that cannot be medically explained
An older perspective for somatic disorders involved only including
symptoms that could not be medically explained. We now know that
patients with medically established diagnoses can have a
disproportionate amount of anxiety or physical symptoms from their
medical disorder. Thus, in DSM-5, it is no longer required for
symptoms to be medically unexplained. Patients with somatic
symptom disorder believe they have an undetected disease, and the
symptoms are typically impairing their lives on a day-to-day basis.
Anxiety and depression are common comorbid symptoms, in
addition to the somatic symptoms with this disorder
12.2.
Which feature differentiates illness anxiety from somatic
symptom disorder?
A. Addiction to internet searches about the feared illness
B. Daily social or occupational impairment
C. Lack of medical evidence to explain the symptoms
D. Need for excessive reassurance from medical doctors
E. No significant physical symptoms
12.2. E. No significant physical symptoms
Similarities between illness anxiety disorder and somatic symptom
disorder include a strong belief that the person has a serious
undiagnosed medical illness despite evidence to the contrary.
Significant impairment in day-to-day functioning remains. These
patients are often addicted to searches about their feared illness and
often seek excessive reassurance from medical providers. Unlike
those with somatic symptom disorder, patients with illness anxiety
disorder do not have significant physical symptoms
12.3.
A patient is in the hospital for being unable to walk and
having fainting spells after being in a car accident. The patient
was driving his car when getting in the accident and witnessed
his friend being killed. Multiple medical workups have not
found any medical explanation for these neurologic symptoms.
Which psychiatric diagnosis is most likely?
A. Conversion disorder
B. Dissociative disorder
C. Factitious disorder
D. Illness anxiety disorder
E. Somatic symptom disorder
12.3. A. Conversion disorder
Patients with conversion disorders, also known as functional
neurologic symptom disorder, often appear to have a neurologic
condition such as a sensory or motor problem, which are found to be
incompatible with true neurologic conditions The symptoms are not
intentionally produced and often follow a trauma or other stressor.
Paralysis, dysphasia, seizures, blindness, or deafness are common
symptoms seen, along with disturbances in consciousness.
12.4.
International Classification of Diseases, Tenth Revision (ICD-
10) criteria for somatization disorder differs from DSM-5
criteria for somatic symptom disorder in which of the
following ways?
A. More than one pain symptom is required
B. No exclusion of a medical cause of the symptoms is required
C. Social or interpersonal impairment is not necessary
D. The duration of the symptoms lasts for a much longer time
frame
E. The patient must be anxious about the symptoms
12.4. D. The duration of the symptoms lasts for a much
longer time frame
While perhaps the major difference between ICD-10 somatization
disorder versus DSM-5 somatic symptom disorder is that the DSM-5
omitted the criteria requiring evidence that there is no underlying
medical cause of the disorder, another difference is that the
symptoms for somatic symptom disorder are only required to last a
relatively short amount of time, more than 6 months, whereas the
ICD-10 criteria for somatization disorder require the symptoms must
last for more than 2 years. Other minor differences include that for
somatic symptom disorder, anxiety about the symptoms is a
necessary criterion.
12.5.
Which of the following test findings is more consistent with a
conversion disorder rather than an underlying neurologic
issue?
A. A patient reporting arm paralysis hits his hand on his face
when his hand is dropped
B. A patient reporting blindness can touch his index fingers
together
C. No flinching is noted when sudden bright lights are flashed
in the eyes of a patient complaining of complete blindness
D. Sensory loss conforming to a specific pattern of distribution
is found in a patient endorsing anesthesia
E. There is an absence of relative afferent pupillary defect in a
patient complaining of blindness in one eye
12.5. E. There is an absence of relative afferent pupillary
defect in a patient complaining of blindness in one eye
In testing for true monocular blindness, the Marcus Gunn, or
swinging flashlight test can be done. If no relative afferent pupillary
defect is noted, it is consistent with a conversion disorder, rather
than actual blindness. Even patients that are fully blind should be
able to touch their index fingers together by proprioception, but
often those with conversion disorder cannot when complaining of
blindness. When bright lights are shown into the eyes of someone
with conversion disorder who is complaining of blindness, typically
flinching is noted. The Hoover test, dropping someone’s hand onto
the face, can test for conversion disorder if the patient’s hand falls
next to, instead of on the face. If the anesthesia is due to conversion
disorder rather than an actual organic problem, typically the sensory
loss does not conform to a specific nerve pattern.
12.6.
An inpatient with many past psychiatric hospitalizations at
various places reports severe depression and hallucinations
after years of no response to various antidepressant
treatments and electroconvulsive therapy (ECT). The patient
reported the depression happened after witnessing a child
being run over and killed. The patient won’t sign consent to
contact any relatives for collateral and reports worsening of
symptoms the day before discharge, with no clear triggers. The
patient is requesting further stay so that more in-depth
medical and psychological testing can be done. This history is
most consistent with which of the following psychiatric
disorders?
A. Conversion disorder
B. Factitious disorder
C. La belle indifference
D. Major depressive disorder
E. Malingering
12.6. B. Factitious disorder
Factitious disorder can be imposed on oneself or others. It involves a
patient feigning to have a medical or psychiatric illness to achieve the
sick role. Unlike with malingering, in factitious disorder, no clear
secondary gain can be found. Elements of the history that can
suggest a factitious disorder include a history of bereavement
involving a violent or bloody death, often in a child. Symptoms of
depression, hallucinations, conversion symptoms, and memory
issues are commonly found. Often, these patients take psychoactive
substances to produce the symptoms. A history of multiple
treatments at various hospitals, along with requests for more tests to
be performed, are common features of a factitious disorder. Another
feature is that the illness does not follow the typical pattern of
remission or show some response to treatment. A flare-up of
symptoms before discharge can also commonly be found.
12.7.
Which of the following history elements should trigger
suspicion of a factitious disorder? Choose four correct
answers.
A. Deterioration early in the hospital stay
B. Fixed fear of having a specific disease
C. History of opiate prescriptions without cause
D. History of working in the health care field
E. Lack of concern about symptoms
F. Resistance to a psychiatric assessment required for surgical
clearance
G. Request for disability papers to be filled out
H. Request for invasive medical treatment
12.7. C. History of opiate prescriptions without cause, D.
History of working in the health care field, F. Resistance to
a psychiatric assessment required for surgical clearance,
and H. Request for invasive medical treatment
Common signs of factitious disorder include the above answers,
along with a patient seeking treatment at various hospitals,
inconsistent information being given, a history of many medical tests
and consultations being performed, findings consistent with selfmanipulation,
and at least one health care worker considering the
diagnoses of factious disorder
12.8.
Which is a physical examination or test finding that can be
indicative of a factious disorder?
A. A fever of 40 °C with diaphoresis
B. Anemia with blood found in the stool
C. Dermatitis on the back
D. Electrocardiogram (EKG) changes along with changes in
creatine kinase levels
E. Healing of chronic wounds when casted
12.8. E. Healing of chronic wounds when casted
A suggestive sign of a factious disorder can include a nonhealing
wound that finally heals when casted. Dermatitis with lesions
distributed in reachable areas (i.e., not on the back) could be a sign
of factitious disorder. High fevers of more than 41 °C with no
diaphoresis or other signs of viral infection are typical for a factious
disorder. Factitious disorder is often indicated by a history of
anemia, but no clear site of bleeding can be found. In a person
feigning an infarction and trying to elevate the creatine kinase levels
by beating themselves, and EKG would not show changes typical of
an infarction.
12.9.
Somatic symptom disorder can be distinguished from
factitious disorder, or malingering, in which of the following
ways?
A. La belle indifference is present
B. No simulations of the reported symptoms are shown
C. Siblings also show unexplained illnesses
D. Symptoms are transient and lack focus on
a specific disease
E. The patient insists on invasive medical procedures
12.9. B. No simulations of the reported symptoms are
shown
Somatic symptom disorder is distinguished from factitious disorder
and malingering in that those with somatic symptom disorder do not
simulate the symptoms they report. La belle indifference can be a
sign of conversion disorder, though is an unreliable one. Siblings
showing unexplained illness can be common in factitious disorders
by proxy. Symptoms of conversion disorder are transient and do not
focus on a particular disease. Seeking invasive or painful procedures
can be a sign of a factitious disorder
12.10.
What percentage of those with conversion disorder is later
diagnosed with a neurologic or nonpsychiatric medical
disorder explaining the symptoms?
A. 0 to 15
B. 25 to 50
C. 50 to 75
D. 75 to 90
E. 85 to 95
12.10. B. 25 to 50
It is important to note that an estimated 25% to 50% of those
classified with a conversion disorder later receive a neurologic or
nonpsychiatric medical diagnosis accounting for their symptoms.
This should serve as a reminder that in all cases of conversion
disorder, a thorough medical and neurologic workup should always
be performed.
12.11.
Somatic symptom disorder is most often comorbid with
which of the following psychiatric disorders?
A. Eating
B. Depressive
C. Posttraumatic
D. Psychotic
E. Substance
12.11. B. Depressive
Depressive and anxiety disorders are highly comorbid with somatic
symptoms disorder. Comorbid medical illnesses can also exist
12.13.
Which is a crucial first step in treating a child once the
diagnosis of a factitious disorder imposed on them by a
parent has been made?
A. Calling child welfare services
B. Discharging the patient from the hospital
C. Educating the parent of the dangers of their actions
D. Notifying the police
E. Performing further medical procedures to
confirm the
diagnosis
12.13. A. Calling child welfare services
In cases of factitious disorder imposed on another, often legal
interventions need to be made. In cases in which the child is being
harmed, notifying child welfare or child protective services is the first
step. The child should not be discharged home, as they might require
placement in another family for safety. The first step is to always
make sure the child is safe. Often an inpatient admission is needed
for safety and to institute a plan.
12.12.
Which antidepressants seem to be more effective for
treatment of pain related to somatic symptom disorders?
A. Dopamine reupdate inhibitors
B. Serotonin antagonist and reuptake inhibitors
C. Serotonin-norepinephrine reuptake inhibitor
D. Selective serotonin reuptake inhibitors
E. Tricyclics
12.12. E. Tricyclics
While CBT has been found to be most effective for the treatment of
somatic symptom disorders, when psychopharmacology is required,
the antidepressants seem to work, with data favoring the older
antidepressants, such as the tricyclics, over the newer ones, such as
the serotonin reuptake inhibitors.
12.14.
A higher prevalence of conversion disorder exists among
which of the following populations?
A. Adults over 35 years old
B. Children under 6 years old
C. Males of all ages
D. People with no prior outpatient psychiatric treatment
E. Surgical referral to a psychiatry consultation service
12.14. E. Surgical referral to a psychiatry consultation
service
Though rare in the general population, around less than 1%,
conversion disorder is found in higher rate (5% to 14%) in medical or
surgical referrals to a psychiatrist consultation liaison service, and in
those receiving outpatient treatment in psychiatric clinics (5% to
25%). Those with conversion disorder tend to be females under the
age of 35 years and children as young as 7 years old have been
reported to have conversion disorder
