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71 Cards in this Set
- Front
- Back
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What are the Somatoform Disorders?
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Medically Unexplained Physical Symptoms (MUPS)
- Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate evaluation |
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Which physical symptoms are commonly unexplained by an organic cause?
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- Chest pain
- Fatigue - Dizziness - Headache - Edema - Back pain - Dyspnea - Insomnia - Abdominal symptoms - Numbness |
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How are Somatoform Disorders differently diagnosed?
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Some depends more on the diagnosing physician's specialty than on any actual difference between the syndromes (eg, neurologist vs psychiatrist)
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How are Somatoform Disorders classified?
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- Psychiatric
- Hypothetical syndromes based on diagnostic criteria |
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What are the consequences on the physician-patient relationship of Medically Unexplained Physical Symptoms (MUPS)?
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Impairs physician-patient relationship
- Physician frustration (the more symptoms the more difficult) - Patient dissatisfaction |
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What are the consequences to the patient with Medically Unexplained Physical Symptoms (MUPS)?
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- Psychosocial distress
- Decreased quality of life - Increased rates of depression and anxiety - Increased healthcare utilization (leads to more harm and patient dissatisfaction than medical benefit, 9x higher medical costs) |
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What are the types of Somatoform Disorders (DSM-IV)?
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- Somatization disorder
- Conversion disorder - Pain disorder - Hypochondriasis - Body Dysmorphic disorder |
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What are the generalities of Somatoform Disorders?
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- Presence of physical symptoms that suggest a general medical condition, but are not explained by a medical condition
- Psychosocial stress = somatic distress - Misinterpretation of normal physiological functions - Not consciously produced or feigned - Alexithymia |
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What is Alexithymia?
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– Individuals who have difficulties expressing emotions verbally
– Correlates positively with: • Depression • Somatization • Hypochondriasis |
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What is the term for individuals who have difficulties expressing their emotions verbally? What is this associated with?
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Alexithymia
– Correlates positively with: • Depression • Somatization • Hypochondriasis |
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What are the DSM-IV-TR criteria for Somatization Disorder?
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• Multiple recurring physical complaints that begin before age 30
• All 4 of the following criteria at some point – 4 pain symptoms – 2 non-pain GI symptoms – 1 sexual complaint – 1 pseudoneurological complaint • Not caused by known medical condition • Not intentionally produced |
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When must Somatization Disorder present by?
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Multiple recurring physical complaints that begin before age 30
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What are the four criteria necessary for diagnosis of Somatization Disorder?
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All of the following:
– 4 pain symptoms – 2 non-pain GI symptoms – 1 sexual complaint – 1 pseudoneurological complaint |
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What is the DSM-5 name for Somatization Disorder? Different criteria?
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Somatic Symptom Disorder
• 1+ somatic symptom that are distressing or result in significant disruption of daily life • Excessive thoughts, feeling, or behaviors related to the somatic symptoms or associated health concerns as manifested by: – Disproportionate and persistent thoughts about seriousness of symptoms – Persistently high level of anxiety about health – Excessive time and energy devoted to these symptoms • State of being symptomatic is persistent (typically greater than 6 months) |
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How common is Somatization Disorder?
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- General population: 0.01%
- Primary care setting: 3% |
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How common is sub-syndromal (does not meet all criteria) Somatization Disorder?
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- General population: 11%
- Primary care setting: 20% |
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How do patients with Somatization Disorder respond to psychiatric care?
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- Rarely seek psychiatric care
- Often refuse psychiatric care due to belief that symptoms are related to undiagnosed primary medical condition |
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What are the clinical features of Somatization Disorder?
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• Patients describe themselves as “sickly”
– Medical histories are circumstantial, vague, inconsistent and disorganized – Describe complaints in dramatic, exaggerated fashion • Large number of outpatient visits • Frequent hospitalizations • Repetitive subspecialty referrals • Large number of diagnoses • Multiple medications |
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What must you rule out before making a diagnosis of Somatization Disorder?
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Primary medical disorders with transient non-specific symptoms:
- MS - Myasthenia Gravis - Systemic Lupus Erythematous (SLE) - AIDS - AIP - Endocrine disorders Psychiatric conditions: - Other somatoform disorders - Depression - Anxiety |
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What are the three features that most suggest a diagnosis of Somatization Disorder instead of another medical disorder?
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– Involvement of multiple organ systems
– Early onset and chronic course without development of physical signs or structural abnormalities – Absence of laboratory abnormalities that are characteristic of the suggested medical condition |
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What are the treatment issues of Somatization Disorder?
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• Schedule regular follow-up visits (limit the number of times they can come in with new complaints)
• Perform a brief physical exam focused on the area of discomfort on each visit • Look closely for objective signs of disease rather than taking the patient’s symptoms at “face value” • Avoid unnecessary tests, invasive treatments, referrals and hospitalizations. • Avoid insulting explanations such as “the symptoms are all in your head” (explain that stress can cause physical symptoms) • Set limits on contacts outside of scheduled visits |
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How effective are the different types of psychotherapy for Somatization Disorder?
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– Not responsive to long-term insight oriented
psychotherapy – Short-term dynamic therapy has shown some efficacy – Cognitive-behavioral therapy has been shown to be effective |
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How effective are the different types of psychopharmacology for Somatization Disorder?
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– Antidepressants have shown inconsistent results
– Antidepressants have limitations in treating somatization disorder • Partial response instead of remission • Higher discontinuation rates –> Sensitive to side effects –> Attribution to physical, whereas antidepressants suggest psychiatric – Unknown long-term efficacy |
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What are the criteria for Conversion Disorder?
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• 1+ symptom affecting voluntary motor or sensory symptoms, suggesting neurological disorder, proceeded by acute, identifiable stressor [no longer needs to be proceeded by acute stressor]
• Clinical findings incompatible with symptom presentation and recognized medical or neurologic illness • 1/3 patients have true neurological illness • 25% recur within the first year |
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What is the DSM-5 term for Conversion Disorder? How is it different in terms of criteria for diagnosis?
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Functional Neurological Symptom Disorder
- No longer needs to be proceeded by an acute stressor |
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What do you need to rule out in patients you think may have Conversion Disorder?
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Neurological illness (1/3 have true neurological illness)
- They may have both - Eg, patient may have documented epileptic seizures and non-epileptic seizures |
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What are the clinical subtypes of Conversion Disorder?
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Motor symptoms or deficits:
- Involuntary movements - Tics - Seizures - Paralysis - Weakness Sensory symptoms or deficits: - Anesthesia - Blindness or tunnel vision - Deafness |
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What are the clinical features of Conversion Disorder?
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• “La belle indifference”: eg, patient develops hemiparalysis when husband is deployed to Iraq, but doesn't seem to care that she can't move her body or will be unable to help kids
• Symptoms likely to occur following stress • Symptoms tend to conform to patients understanding of neurology • Inconsistent physical exam (make sure you document what you see to not inconsistencies) |
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How do you treat Conversion Disorder?
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• Conservative treatment
– Reassurance (eg, if you give them a way to improve they often will - have them go to PT/OT and tell them you expect a full recovery) • Address stressors • Protective environment • Appropriate workup has been done and full recovery is expected – Physical and occupation therapy • Psychotherapies • Amytal interview, hypnosis – If the symptom can be resolved by these modalities, they are probably the result of a conversion disorder |
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If a patients symptoms are resolved by an amytal interview or hypnosis, what is likely the diagnosis?
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Conversion disorder
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What are the good prognostic factors for Conversion Disorder?
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– Onset following a clear stressor
– Prompt treatment – Symptoms are paralysis, aphonia, or blindness |
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What are the poor prognostic factors for Conversion Disorder?
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– Delayed treatment
– Symptoms of seizures or tremor |
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What are the criteria for Pain Disorder (DSM-IV) - now eliminated from DSM-5?
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• Pain in 1+ anatomical sites is the predominant focus of clinical attention or is of significant severity to warrant clinical attention
• Complaints of pain are significantly affected by psychological factors • Psychological factors are required in the: – Genesis of the pain – Severity of the pain – Maintenance of the pain • Pain is not intentionally produced or feigned |
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What is the name of Pain Disorder in DSM-5? How is it different from DSM-IV?
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It has been eliminated from DSM-5
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What are the clinical features of Pain Disorder?
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• Pain may take various forms
• Pain is severe and constant • Pain may be disproportionate to underlying condition • Psychological factors predominate • Pain is often the main focus of the patient’s life |
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What is the differential diagnosis for Pain Disorder?
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• Purely physical pain
• Depression • Other somatoform disorders • Substance use disorders • Malingering • Factitious disorder |
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How do you treat Pain Disorder?
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• General
– Stress an understanding that the pain is real – Goal is likely an improvement in functioning rather than a complete relief of pain • Cognitive-behavioral therapy – Relaxation therapy – Biofeedback • Hypnosis • Pharmacotherapy (eg, SNRIs, Gabapentin) and treat underlying mood disorders |
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What are the good prognostic factors for Pain Disorder?
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– Resolution of litigation
– Prompt treatment |
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What are the poor prognostic factors for Pain Disorder?
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– Pre-existing character pathology
– Pending litigation – Use of addictive substances – Prolonged history of pain complaints |
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What are the symptoms/criteria of Hypochondriasis? How long does it last?
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• Preoccupation with fears of having a serious illness that does not respond to reassurance after appropriate medical work-up
• Belief not of delusional intensity and is not restricted to concern about appearance • Duration of at least 6 months |
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What is the DSM-5 term for Hypochondriasis? Different symptoms?
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Illness Anxiety Disorder
- Somatic symptoms typically not present, but if they are, only mild in intensity (eg, may fear they have a brain tumor but not experiencing numbness, tingling, etc) - High level of anxiety about health and easily alarmed about personal health status |
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What are the clinical features of Hypochondriasis?
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• Bodily preoccupation
• Disease phobia • Disease conviction • Onset in early adulthood • Chronic with waxing and waning of symptoms |
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How do you treat Hypochondriasis?
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• General aspects
– Establishment of trust – History taking – Identification of stressors – Education • Cognitive-behavioral therapy (beneficial) • Supportive therapy • Pharmacotherapy – Serotonergic meds appear to most beneficial |
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What is the best kind of therapy for Somatoform Disorders?
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Cognitive Behavioral Therapy
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What are the criteria of Body Dysmorphic Disorder in DSM-IV?
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• Pervasive feeling of ugliness of some aspect of their appearance despite a normal or nearly normal appearance
• If slight physical anomaly is present, person’s concern is markedly excessive |
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What is the new name for Body Dysmorphic Disorder in DSM-5? New criteria?
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OCD Anxiety Disorder
- Repetitive behaviors or mental acts in response to appearance concerns (eg, looking in the mirror all of the time) |
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How common is Body Dysmorphic Disorder? Which settings does it present in?
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Unknown in general population
- Dermatologic setting: 12% - Cosmetic surgery setting: 6-15% |
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What are the clinical features of Body Dysmorphic Disorder? Onset?
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• Appearance preoccupation
– Any body part – Most often involve the face or head – Typically think about flaws 3-8 hours/day • Compulsive behaviors – Intent to examine, improve, seek reassurance or hide perceived defect • Medical or surgical treatment complications Onset: between 15-30 years |
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What are the gender differences for Body Dysmorphic Disorder?
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Women
• Hips • Breasts Men • Body build • Genitals • Thinning hair |
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What are the most common comorbidities of Body Dysmorphic Disorder?
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• Major depression: 60-80%
• Social phobia: 38% • Substance use: 36% • Obsessive compulsive disorder: 30% • Personality disorders: 57-100% (Avoidant PD is most common) |
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How do you treat Body Dysmorphic Disorder?
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• General - avoid iatrogenic harm!
• Cognitive-behavioral therapy • Pharmacotherapy – Serotonin-specific medications (may reduce symptoms in ~50% patients) – High-dose and delayed response (10-12 weeks) • “Corrective” surgery does NOT work – Potential cause of litigation |
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What disorder/syndrome differs from Somatoform Disorders in that signs and symptoms are intentionally produced?
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Deception Syndromes
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What are the methods of inducing illness in patients with Deception Syndrome?
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– Exaggerations
– Lies – Tampering with tests to produce positive results – Manipulations that cause actual physical harm |
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What are the types of Deception syndromes?
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- Factitious Disorder
- Malingering |
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What are the DSM-IV criteria for Factitious Disorder?
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– Intentionally exaggerates or induces signs and symptoms of illness.
– Motivation is to assume the sick role – External incentives for the illness inducing behavior are absent |
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How common is Factitious Disorder?
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– Prevalence in general population is unknown
– Diagnosed in about 1% of patients seen in psychiatric consultation in general hospitals • Likely higher in referral centers |
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What causes Factitious Disorder?
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• Little data is available since these patient resist psychiatric intervention.
• Many patients suffered childhood abuse resulting in frequent hospitalizations – Hospitals viewed as safe • Self-enhancement model – Factitious disorder may be a means of increasing or protecting self-esteem |
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What is the most severe form of Factitious Disorder?
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Muchausen Syndrome
- 10% of Factitious Disorder patients - Severe and chronic - "Pseudologia fantastica" |
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What is Pseudologia fantastica associated with?
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Muchausen Syndrome
- Compulsive lying or pathological lying, is a behavior of habitual or compulsive lying |
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What are the types of Factitious Disorders?
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- Munchausen Syndrome
- Factitious Disorder by Proxy - Ganser's Syndrome |
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What are the characteristics of Factitious Disorder by Proxy?
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A person intentionally produces physical signs or symptoms in another person under the first person’s care
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What are the characteristics of Ganser's Syndrome?
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Characterized by the use of approximate answers
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What are the methods of inducing Factitious Illness?
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• Exaggerations
• Lies • Tampering with tests to produce positive results (eg, syringe in their bed with bacteria in it that is now in their blood) • Manipulations that cause actual physical harm |
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What is the differential diagnosis for Factitious Disorder?
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• Must establish the intentional and conscious production of symptoms
– Direct evidence – Excluding other causes • True physical illness • Other somatoform disorders • Malingering |
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What are the predisposing factors for Factitious Disorders?
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• True physical disorders in childhood leading to extensive medical treatment
• Employment (present or past) as a medical paraprofessional • Severe personality disorder |
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What are the comorbidities of Factitious Disorder?
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• Anxiety
• Depression • Personality disorders (Borderline personality disorder is the most prevalent) |
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What is the typical hospital admission presentation of a patient with Factitious Disorder?
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– Weekend or late night admission
– Praise then punish and demand behavior while hospitalized – Anger from treatment team – Discharge – Readmission to another hospital |
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How do you manage patients with Factitious Disorder?
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• No specific treatment shown effective
• Early identification • Prevent iatrogenesis • Beware of negative countertransference • Be mindful of legal and ethical issues • Address any psychiatric diagnosis underlying the factitious disorder diagnosis (rarely allowed by the patient) |
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What is the diagnosis for a patient with intentional production of feigning illness?
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Malingering
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What are the motivations for Malingering?
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External incentives:
- Drugs - Litigation - Financial compensation - Avoidance of work/military - Evade criminal prosecution |
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When should you strongly consider a diagnosis of Malingering?
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– Medicolegal presentation
– Marked discrepancy between person’s claimed stress/disability and objective findings – Lack of cooperation with evaluation and treatment – Antisocial personality disorder |
