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77 Cards in this Set
- Front
- Back
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What is the disorder in patients who present with enduring physical symptoms without an identifiable organic cause, which causes significant distress or impairment in social, occupational, or other areas of functioning?
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Somatoform Disorders
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What do patients with Somatoform Disorder think is causing their symptoms?
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Medical problems - they are not consciously feigning their symptoms
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What is the term for patients who consciously feign symptoms in order to get something?
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Malingering
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What are Somatoform Disorders?
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- Physical symptoms without identifiable organic cause - Causes significant distress or impairment in social, occupational, or other areas of functioning - Symptoms result in primary and secondary gains - Patients believe their symptoms are due to medical problems |
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What is meant by "primary gain"?
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Symtoms as an unconscious defense against unacceptable INTERNAL conflicts (self-justification for various actions or lack of actions)
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What is meant by "secondary gain"?
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Symptoms that provide unconscious EXTERNAL benefits (increased attention from others, decreased responsibilities, avoidance of the law, etc)
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What are examples of Somatoform Disorders?
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- Somatization disorder - Conversion disorder - Hypochondriasis - Pain disorder - Body dysmorphic disorder - Undifferentiated somatoform disorder - Somatoform disorder NOS |
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What do you need to do when you suspect a somatoform disorder?
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Rule out organic causes of symptoms with a comprehensive medical workup
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Who is more likely to have a Somatoform Disorder?
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Women
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What is often comorbidin patients with Somatoform Disorders?
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Half of patients have comorbid mental disorders: - Anxiety disorder - Major depression |
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Case:31yo woman referred to psych by gynecologist after undergoing multiple exploratory surgeries for abdominal pain and gynecologic concerns with no findings. She has had extensive medical problems dating back to adolescence. She reports periods of extreme abdominal pain, vomiting, diarrhea, and possible food intolerances. The OB is her 4th provider because "my other docs were not able to help me." Her current physician will also fail to relieve her distress. She was reluctant to see a psych but did so only after her OB agreed to follow her after her psych appt.
She reports problems worsened in college, which was the first time she had surgery. Took her 5.5 years to graduate d/t health problems and lack of energy. She feels very lonely and isolated because she can't find a bf who will tolerate her illness. Physical intimacy is difficult b/c sex is painful. Worried she may lose her job d/t days missed d/t abdominal pain, fatigue, and weakness.
What is the most likely diagnosis? |
Somatization disorder - Hx of multiple complaints in multiple organ systems - Waxed and waned over time - No clear cause after extensive workup - Multiple medical procedures that did not relieve symptoms - Frequently changed providers - Sx started before age 30y; significant impairment in social and occpuational functioning |
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Patients with somatization disorder present with what symptoms?
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- Multiple, often non-specific, physical symptoms involving many organ systems - Seek treatment from many doctors, often resulting in extensive lab work, diagnostic procedures, hospitalizations, and/or surgeries |
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How common is somatization disorder in primary care?
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5-10% of patients
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What are the DSM-IV criteria for somatization disorder?
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- Onset before 30y - >/= 4 pain symptoms - >/= 2 GI symptoms - >/= 1 sexual / reproductive symptom - >/= 1 pseudoneurological symptom, not limited to pain - Cannot be explained by general medical condition or substance use - When a general medical condition is present, physical complaints are in excess of what would be expected - Symptoms must not be intentionally produced |
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How common is somatization disorder? Men vs women?
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- Lifetime: 0.1-0.5% - 5-10% of primary care patients - Incidence in females 5-20x > males |
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How common are comorbid medical disorders in patients with somatization disorder?
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50%
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How often does an identical twin of someone with somatization disorder also have somatization disorder?
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30% concordance rate
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Patients with somatization disorder often have what history?
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Sexual and/or physical abuse
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How is somatization disorder different from conversion disorder?
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- Pts with somatization disorder typically express lots of concern over their condition and chronically perseverate over it - Pts with conversion disorder often have an abrupt onset of their "disability" (blindness, etc) and they are usually apathetic about it |
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What "mnemonic" can help you remember the characteristics of somatization disorder?
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SOMAtization = SO MAny physical complaints
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What are the symptom requirements for somatization disorder?
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- >/= 4 pain symptoms - >/= 2 GI symptoms - >/= 1 sexual / reproductive symptom - >/= 1 psuedoneurological symptom, not limited to pain |
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What is the course of somatization disorder?
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- Chronic and debilitating - Periodic improvement and worsening under stress |
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How should you manage / treat a patient with somatization disorder?
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- They should have regularly scheduled visits with a single primary care phsyician, who limits, but does not eliminate, medical workups - Address psychological issues slowly; pts will likely resist referral to a mental health professional |
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What are the characteristics of conversion disorder?
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- At least 1 neurological symptom (sensory or motor) that cannot be explained by a medical disorder - Onset is usually preceded or exacerbated by a psychological stressor, although the pt may not connect these two - Pts are often surprisingly calm and unconcerned (la belle indifference) when describing their symptoms |
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What are examples of neurological symptoms that may be present in conversion disorder?
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- Blindness - Paralysis - Paresthesia |
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What "mnemonic" can help you remember the characteristics of conversion disorder?
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CONVERsion disorder: pts CONVERt their psychiatric problems into a neurological problem and then spontaneously "CONVERt back to normal
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How do patients with conversion disorder feel about their neurological symptom(s)?
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They are often surprisingly calm and unconcerned ("la belle indifference")
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What are the DSM-IV critieria for conversion disorder?
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- At least 1 neurological symptom - Psychological factors associated with initiation or exacerbation of symptoms - Not intentionally feigned or produced - Cannot be explained by medical condition or substance use - Causes significant distress or impairment in social or occupational functioning or warrants medical evaluation - Not limited to pain or sexual dysfunction, and not better accounted for by a different mental disorder |
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What are common symptoms of conversion disorder?
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- Shifting paralysis - Blindness - Mutism - Paresthesias - Seizures - Globus hystericus (sensation of lump in throat) |
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What is meant by the term "la belle indifference"?
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Pts are calm and unconcerned when describing their symptoms
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What is meant by "globus hystericus"?
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Sensation of a lump in the throat
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If you see conversion-like presentation in elderly, what do you need to be aware of?
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These patients have a higher likelihood of representing a real neurological deficit
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Conversion disorder is more common in men or wmoen? Typical age of onset?
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- Women > Men - Onset at any age, but most often in adolescence or early adulthood |
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What comorbid disorders are more common in conversion disorder?
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- Schizophrenia - Major depression - Anxiety disorders |
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What is the course / prognosis for conversion disorder?
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- Symptoms may be brief or last several weeks or longer; most patients spontaneously recover - 25% will eventually have future episodes, especially during times of stress |
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How should you treat conversion disorder?
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- Insight-oriented psychotherapy - Hypnosis - Relaxation therapy
- Most patients spontaneously recover |
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What are the DSM-IV criteria for hypochondriasis?
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- Preoccupation with fear of having or contracting a seroius disease, based on misinterpreting bodily symptoms - Persists despite medical evaluation and reassurance - Not of delusional intensity and not restricted to a circumscribed concern about appearance - Significant impairment in functioning - Persists for at least 6 months - Not better accounted for by another mental disorder |
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How long do symptoms of hypochondriasis need to be present for diagnosis?
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6 months
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Are men or women more affected by hypochondriasis? Typical age of onset?
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- Men = Women - Average age of onset: 20-30y |
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How common is comorbid depression or anxiety in hypochondriasis?
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80%
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What is notable about hypochondriasis in terms of incidence in men or women?
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Hypochondriasis is the only somatoform disorder that does not have a higher frequency in women
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How should you treat hypochondriasis?
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- Regularly scheduled visits to one PCP - Comorbid anxiety / depression should be treated with SSRIs or other psychotropic meds - Cognitive behavioral therapy (CBT) is most useful |
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What ist he prognosis of hypochondriasis?
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- Episodic: symptoms may wax and wane periodically - Exerbations occur commonly under stress - Up to 50% improve significantly |
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What are the better prognostic factors for hypochondriasis?
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- Higher socioeconomic status - Treatment-responsive anxiety or depression - Absence of comorbid medical conditions and personality disorders |
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What is the disorder that causes patients to be preoccupied with body parts that they perceive as flawed or defective, having strong beliefs that they are unattractive or repulsive?
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Body Dysmorphic Disorder
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What are the characteristics of Body Dysmorphic Disorder?
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- Preoccupation with body parts they perceive as flawed or defective - Strong beliefs that they are unattractive or repulsive - Physical imperfections are either minimal or completely imagined, they view themselves as severe and grotesque - Very self-conscious - Spend significant time trying to correct perceived flaws with makeup, dermatological procedures, or plastic surgery |
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What are the DSM-IV criteria for diagnosing Body Dysmorphic Disorder?
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- Pre-occupation with an imagined defect in appearance or excessive concern about a slight physical anomaly - Must cause significant distress in patient's life - Not better accounted for by another mental disorder |
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Body Dysmorphic Disorder is more common in men or women? Typical age of onset?
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- Women > Men - Onset: 15-20 y - More common in unmarried persons |
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What disorders is there a high comorbidity of with Body Dysmorphic Disorder?
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- Depression - Anxiety - Psychotic disorders |
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How should you treat Body Dysmorphic Disorder?
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- Surgical or dermatologic procedures are routinely unsuccessful in pleasing the patient - SSRIs may reduce symptoms in 50% of patients |
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What is the course / prognosis of Body Dysmorphic Disorder?
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- Onset usually gradual - Symptoms may be chronic or they may wax and wane in intensity |
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Patients with "pain disorder" may have what symptoms?
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- Prolonged, severe discomfort without an adequate medical explanation - Pain often coexists with a medical condition but is not directly caused by it or fully explained by it |
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Patients with "pain disorder" is either acute or chronic as established by what?
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- Acute <6 months - Chronic >6 months |
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What are the DSM-IV criteria for pain disorder?
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- Patient's main complaint is pain at one or more anatomic sites, of sufficient severity to warrant clinical attention - Pain causes significant distress or impairment in the patient's life - Psychological factors play an important role in the pain - Not intentionally produced - Not better accounted for by a mental disorder or meet criteria for dyspareunia |
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How does gender affect the incidence of pain disorder? Typical age of onset?
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- Women are 2x as likely as men to have pain disorder - Age of onset: 30-50y |
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Who is more likely to have pain disorder?
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- Women - Increased incidence in first-degree relatives - Increased incidence in blue-collar workers |
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Patients with pain disorder have a higher incidence of what comorbid disorders?
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- Major depression (may exacerbate the symptoms of pain disorder) - Anxiety disorders - Substance abuse |
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What is the prognosis for pain disorder?
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Usually increases in intensity for first several months and often becomes chronic and disabling
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How should you treat pain disorder?
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- SSRIs - Biofeedback - Hypnosis - Psychotherapy - Analgesics are not helpful, and patients often become dependent on them |
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What are the characteristics of "factitious disorders"?
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- Pts intentionally produce medical or psychological symptoms in order to assume the role of a sick patient - Often do this in a way that can cause real danger (central line infections, insulin injections, etc) - Primary gain is a prominent feature of this disorder |
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What are the DSM-IV criteria for "factitious disorder"?
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- Pts intentionally produce signs of physical or mental disorders - Produce the symptoms to assume the sick role (primary gain) - Lack of secondary gain distinguishes it from malingering |
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What are the commonly feigned symptoms in "factitious disorder"?
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- Psychiatric: hallucinations, depression, pseudologia fantastica - Medical: fever (by heating thermometer), abdominal pain, seizures, skin lessions, hematuria |
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How common is "factitious disorder" in hospitalized patients?
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Up to 5%
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Who is more likley to have "factitious disorder"?
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- Higher incidence in hospital and health care workers (who have learned how to feign symptoms) - Associated with higher intelligence, poor sense of identity, and poor sexual adjustment - Many pts have hx of child abuse or neglect |
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What is another name for "factitious disorder" with predominantly physical complaints?
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Munchhausen Syndrome
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What is the name for intentionally producing symptoms in someone else who is under one's care?
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Munchhausen Syndrome by Proxy
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How do you treat "factitious disorder"?
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- Collect collateral information from medical treaters and family - Collaborate with PCP to avoid unnecessary procedures - Avoid early confrontation - pts who are confronted while in the hospital often leave AMA and seek hospitalization elsewhere |
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What is the prognosis for "factitious disorder"?
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Repeated and long-term hospitalizations are common
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Case: Pt claims he has frequent episodes of seizures, starts on meds, and joins an epilepsy suport group. It becomes known that he is doing this in order to collect disability money.
Most likely diagnosis? |
Malingering
(In contrast, "factitious disorder" patients look for some kind of emotional gain by playing the "sick role," such as sympathy from the physician. Fundamental difference is the intention of the patient) |
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What is the primary difference between malingering and factitious disorder?
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- Malingering: gain is external - Factitious disorder: gain is internal |
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What are the characteristics of malingering?
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Feigning of physical or psychological symptoms in order to achieve personal gain |
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What are common motivators for malingering?
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- Avoid the police - Receive room and board - Obtain narcotics - Receive monetary compensation |
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How do patients with malingering typically present?
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- Multiple vague complaints that do not conform to a known medical condition - Often have a long medical history with many hospital stays - Generally uncooperative and refuse to accept a good prognosis even after extensive medical eval - Sx improve once their desired objective is obtained |
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How common is malingering in hospital patients? Men vs women?
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Common; men > women
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What are the distinguishing features of somatoform disorders?
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Pts believe they are ill and do not intentionally produce or feign symptoms
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What are the distinguishing features of factitious disorders?
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Pts intentionally produce symptoms of real illness because of a desire to assume the sick role, not for external rewards
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What are the distinguishing features of malingering?
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Pts intentionally produce or feign symptoms for external rewards
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