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Psychiatry Clerkship > Somatic Symptom and Related Disorders > Flashcards

Somatic Symptom and Related Disorders Flashcards

1
Q

Shared features of somatic symptom and related disorders?

A
  1. Distressing somatic symptoms + abnormal thoughts, feelings, and behaviors in response to these symptoms
  2. Commonly encountered in primary care and other medical settings and less so in mental health settings
  3. Symptoms can be linked to medically explainable and unexplainable problems
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2
Q

Factors contributing to somatic symptom and related disorders?

A
  • Genetic and biological vulnerability (such as increased sensitivity to pain)
  • Early traumatic experiences
  • Learning (eg, attention from illness, no reinforcement of non-physical expressions of distress)
  • Cultural/social norms that devalue/stigmatize psychological suffering as compared with physical suffering
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3
Q

DSM-5 Criteria for Somatic Symptom Disorder?

A

A. 1+ somatic symptoms that are distressing or result in significant disruption of daily life
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least 1 of the following:
-Disproportionate and persistent thoughts about the seriousness of one’s symptoms
-Persistently high level of anxiety about health or symptoms
-Excessive time and energy devoted to these symptoms or health concerns
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)

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4
Q

Specifiers for Somatic Symptom Disorder?

A

-With prominent pain (previously pain disorder)
-Persistent (severe symptoms, marked impairment, >6 months)
-Severity:
Mild (1-2 symptoms)
Moderate (2+ symptoms)
Severe (2+ symptoms + multiple somatic complains or one very severe complaint)

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5
Q

Associated cognitive features that support Dx of Somatic Symptom Disorder?

A

Focus on somatic symptoms
Attribution of normal bodily sensations to physical illness
Concern about sickness
Fear of physical activity harming the body
Sensitization to pain

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6
Q

Associated behavioral features that support Dx of Somatic Symptom Disorder?

A

Repeated bodily checking for abnormalities
Repeated seeking of medical help/reassurance
Associated with depressive disorders leading to increased suicide risk

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7
Q

Prevalence of Somatic Symptom Disorder?

A

5-7%

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8
Q

M vs. F - Somatic Symptom Disorder?

A

F>M

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9
Q

Presentation of Somatic Symptom Disorder in children?

A
  • Common symptoms: recurrent abdominal pain, headaches, fatigue, nausea
  • More likely to have single symptom
  • Not as much associated worry about illness prior to adolescence
  • Parents’ reactions can determine level of distress
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10
Q

Presentation of Somatic Symptom Disorder in older adults?

A
  • Often underdiagnosed (physical symptoms of fatigue/pain thought to be normal part of aging, normalization of illness worry because of more general medical illnesses and medications than younger people)
  • Depression is a common comorbidity
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11
Q

Risk/prognostic factors of Somatic Symptom Disorder?

A
  • Temperament (neuroticism is a risk factor), comorbid depression/anxiety
  • Lower education level, lower SES, history of stressful life events
  • Course modifiers: ongoing chronic illnesses, social stress, reinforcing social factors such as illness benefits
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12
Q

Rx - Somatic Symptom Disorder

A
  • PCP: identify one single primary caregiver, brief scheduled visits with no new work-up, referral
  • Mental health provider: therapeutic alliance, reassurance, psychotherapy, role of medications
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13
Q

DSM-5 Diagnostic Criteria - Illness Anxiety Disorder

A

A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are not present or are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate
C. High level of anxiety about health, easily alarmed about personal health status
D. Excessive health realted behaviors (repeatedly checking his or her body for signs of illness), maladaptive avoidance
E. Present for at least 6 months, but the specific illness that is feared may change over that period of time
F. Not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, GAD, BDD, OCD, or delusional disorder (somatic type)

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14
Q

Specifiers for Illness Anxiety Disorder

A

Care-seeking type: medical care is frequently used

Care-avoidant type: medical care rarely used

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15
Q

Features of Illness Anxiety Disorder?

A
  • Comprehensive evaluation cannot attribute a serious medical condition to symptoms
  • If medical condition exists, anxiety and preoccupation with condition are excessive and disproportionate
  • Physical sign or symptom often normal physiological sensation, benign self-limited dysfunction, or a bodily discomfort not generally indicative of disease
  • Found primarily in primary care setting
  • Use a lot of medical resources
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16
Q

Comorbidities of Illness Anxiety Disorder?

A

2/3 likely to have at least one, especially somatic symptom disorder and personality disorder

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17
Q

Possible etiologies of Illness Anxiety Disorder?

A
  • Cognitive - misinterpret bodily symptoms
  • Learning model - sick role
  • Psychodynamic - repression, displacement
  • Variant - 80% have coexisting anxiety or depressive disorder
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18
Q

Prevalence of Illness Anxiety Disorder?

A

1.3-10%

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19
Q

M vs. F in Illness Anxiety Disorder?

A

M = F

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20
Q

Onset of Illness Anxiety Disorder?

A

Early and middle adulthood

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21
Q

Risk factors for Illness Anxiety Disorder?

A

Major life stress

History of childhood illness or abuse

22
Q

Course/prognosis of Illness Anxiety Disorder?

A

Tends to be chronic and relapsing

Up to 1/2 improve significantly

23
Q

Good prognostic indicators of Illness Anxiety Disorder?

A
  • High SES
  • Sudden onset
  • Rx responsive depression/anxiety
  • No personality disorder
  • No medical condition
24
Q

Rx - Illness Anxiety Disorder?

A
  • Emphasis on stress reduction and coping with chronic illness, group psychotherapy (insight oriented, CBT)
  • Primary care - regularly scheduled visits, low frequency of investigations, logging of symptoms and concerns
  • Pharmacotherapy - only responsive if treatment responsive underlying disorder
25
Q

DSM-5 Diagnostic Criteria - Conversion Disorder (aka Functional Neurological Symptom Disorder)

A

A. 1+ symptoms of altered voluntary motor or sensory function
2. Clinical findings provide evidence of incompatibility between the symptoms and recognized neurological or medical conditions
C. Symptom or deficit not better explained by another medical or mental disorder
D. Causes clinically significant distress/impairment, etc.

26
Q

Specifiers for Conversion Disorder?

A

Symptom type (weakness or paralysis, abnormal movements, swallowing symptoms, speech symptoms, attacks or seizures, anesthesia or sensory loss, special sensory symptom, mixed)

  • Acute (<6 months) or persistent (>6 months)
  • Psychological stressor or without psychological stressor
27
Q

Motor subtypes of conversion disorder?

A
  • Tremors of limbs, head, or trunk (may increase with attention)
  • Impaired balance and coordination (astasia abasia)
  • Psychogenic paralysis (normal neuro exam)
28
Q

Sensory subtypes of conversion disorder?

A
  • Loss of sensation of touch/pain (often midline)
  • Psychogenic blindness/deafness
  • Hallucinations
29
Q

Non-epileptic seizures/pseudoseizures?

A
  • Often linked to a stressor, variable onset, increased frequency and longer in duration each time
  • Often occur in presence of others
  • Rarely bite tongue, incontinence, or associated injury
  • No postictal confusion
  • Maintaining pupillary and corneal reflexes
  • Concurrent EEG with no epileptiform activity and no post-seizure rise in Prl
30
Q

Examples of internal inconsistencies?

A
  • Hoover’s sign
  • Weakness of ankle plantar-flexion when supine but intact ability to walk on tip toes
  • Closed eyes with resistance to opening or a normal EEG (psychogenic seizures)
31
Q

History of patients with conversion disorder?

A
  • Maladaptive personality traits
  • Possible hx of childhood abuse or neglect or stressful life events
  • Onset may be linked with stress or trauma
  • Often associated with dissociative symptoms (depersonalization, derealizaiton, dissociative amnesia)
32
Q

Lifetime prevalence of conversion disorder?

A

11-500/100,000

33
Q

M vs. F - conversion disorder?

A

2:1 F>M

34
Q

Onset of conversion disorder?

A

Adolescents and young adults, but can happen at anytime

35
Q

Conversion disorder more common in what populations?

A 
Rural
Less education
Low IQ
Low SES
Combat exposure in military
36
Q

Possible etiologies of Conversion Disorder?

A
  • Psychoanalytic (repression of unconscious intrapsychic conflict and the conversion of anxiety into a physical symptom)
  • Biologic - hypometabolism of dominant hemisphere and dysfucntional hypermetabolism of non-dominant hemisphere leading to impaired interhemispheric communication, increased cortical arousal leading to inhibition of awareness of bodily sensation
  • Significant history of abuse
  • Monozygotic > Dizygotic
37
Q

Features of conversion disorder?

A
  • La belle indifference - lack of concern about nature or implications of symptoms
  • Identification (unconscious modeling)
38
Q

Rule of 1/3 - conversion disorder?

A

1.3 - re-diagnosed with a neurological problem
1/3 - maintain dx of pseudoseizure with a coexisting seizure disorder
1/3 - maintain diagnosis of pseudoseizure

39
Q

Course of conversion disorder?

A

Transient symptoms are common

  • Initial symptoms may resolve in first few days to 1 month
  • Remission in 2 weeks if stressor is addressed
  • 75% with no other episode
  • 25% with additional episode
40
Q

Good prognostic indicators of conversion disorder?

A 
Sudden onset
Identifiable stressor
Good premorbid functioning
No comorbidities
No litigation
Younger children > adults/adolescents
41
Q

Rx - conversion disorder

A

Usually spontaneous resolution
-Alliance, avoid confrontation, decrease stressors, relaxation techniques, psychotherapy as needed, medication (anxiolytics may help)

42
Q

DSM-5 Criteria - Psychological Factors Affecting other Medical conditions?

A

A. Medical symptom or condition (other than a mental disorder) is present
B. Psychological or or behavioral factors adversely affect the medical condition in one of the following ways:
-Factors have influenced course of medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition
-Factors interfere with treatment of the medical condition
-Factors constitute additional well-established health risks
-Factors influence underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention
C. Psychological and behavioral factors are not better explained by another mental disorder

Can specify severity
Mild - increases medical risk
Moderate - aggravates medical condition
Severe - results in hospitalization or ER visit
Extreme - severe, life-threatening risk
43
Q

List some psychological or behavioral factors.

A

Psychological distress
patterns of interpersonal interaction
Coping styles
Maladaptive health behaviors (denial of symptoms, poor adherence to medical recs)

44
Q

DSM-5 Diagnostic Criteria of Factitious Disorder imposed on self?

A

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception
B. Individual presents himself/herself to others as ill, impaired, or injured
C. Deceptive behavior evident even in the absence of obvious external rewards
D. Behavior not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

45
Q

DSM-5 Diagnostic Criteria of Factitious Disorder imposed on another?

A

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception
B. Individual presents another individual (victim) to others as ill, impaired, or injured
C. Deceptive behavior evident even in the absence of obvious external rewards
D. Behavior not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

Perpetrator receives this diagnosis (not the victim)

46
Q

Etiology of Factitious Disorder?

A
  • Not well-understood
  • Case reports suggest history of childhood abuse/neglect -> inpatient hospitalizations -> nurturing escape from abusive home environment
  • Recreating a rejecting parent-child relationship with physicians
  • Masochistic personality (seek painful procedures)
47
Q

Rx - Factitious Disorder?

A 
Management, not cure
3 major goals:
-Reduce risk of morbidity and mortality
-Address underlying mental health needs
-Consider legal/ethical issues
Foster good communication between medical/surgical provider and psychiatrist
48
Q

DSM-5 Criteria - Other Specified Somatic Symptom and Related Disorder?

A

Presentations in which symptoms characteristic of somatic symptom and related disorder that cause clinically significant distress or impairment predominate, but do not meet full criteria for any disorders

49
Q

Brief somatic symptom disorder?

A

Duration < 6 months

50
Q

Brief illness anxiety disorder

A

Duration < 6 months

51
Q

Illness anxiety disorder without excessive health-related behaviors?

A

Criterion D not met

52
Q

Pseudocyesis?

A

False belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy

Psychiatry Clerkship (8 decks)

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