Chapter 7 Diagnostic and Statistical Manual of Mental Disorders and Pain Management Flashcards Preview

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Flashcards in Chapter 7 Diagnostic and Statistical Manual of Mental Disorders and Pain Management Deck (49):
1

Somatoform disorders

grouped together by the presence of physical symptoms suggesting a general medical condition. These symptoms are not explained fully by a general medical condition, or by the effects of substances or other mental disorders. There is no diagnosable medical
condition to fully account for the physical symptoms,
and there must be a significant functional impairment. In contrast to factitious disorders and malingering, the symptoms in somatoform disorders are involuntary

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Somatization

described as a tendency to experience and communicate somatic distress and symptoms
unaccounted by pathologic findings, to attribute them to physical illness, and to seek medical help for them

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differential diagnosis of somatoform disorder.

differential diagnosis should also include unrecognized organic disease, anxiety, substance abuse,
cognitive dysfunction, and psychosis

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essential feature of somatization disorder

a pattern of recurring, multiple, clinically significant somatic
complaints that may result in medical treatment or functional impairments

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Diagnostic Criteria for Somatization Disorder --Criterion A

A history of many physical complaints beginning before age 30 that occur over a period of several years and result in
treatment being sought or significant impairment in social, occupational, or other important areas of functioning

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Diagnostic Criteria for Somatization Disorder --Criterion B

Each of the following criteria must have been met, with individual symptoms occurring at any time during the course
of the disturbance:
1. Four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back,
joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination).
2. Two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea,
bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods).
3. One sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual
indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting
throughout pregnancy).
4. One pseudoneurologic symptom: a history of at least one symptom or deficit suggesting a neurologic condition not
limited to pain (conversion symptoms such as impaired coordination or balance, paralysis, or localized weakness,
difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation,
double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other
than fainting)

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Diagnostic Criteria for Somatization Disorder --Criterion C

Either (1) or (2):
1. After appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse or medication).
2. When there is a related general medical condition, the physical complaints or resulting social or occupational
impairment are in excess of what would be expected from the history, physical examination, or laboratory findings.

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Diagnostic Criteria for Somatization Disorder --Criterion D

The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).

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Screening Test for Somatization Disorder

If two or more symptoms are
present, there is a high likelihood of somatization disorder

Mnemonic --> Symptom (System)
Somatization--> Shortness of breath (Respiratory)
Disorder--> Dysmenorrhea (Female reproductive)
Besets--> Burning in sex organ (Psychosexual)
Ladies --> Lump in throat (difficulty swallowing) (Pseudoneurologic)
And --> Amnesia (Pseudoneurologic)
Vexes--> Vomiting (Gastrointestinal)
Physicians--> Painful extremities (Skeletal muscle)

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Three features that
suggest somatization as opposed to a general medical condition
are

multiple organ system involvement, early onset,
and chronic course without objective signs, and absence
of laboratory abnormalities

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How do individuals with somatization disorder usually describe complaints?

in exaggerated terms or grandiose fashion, often lacking specific facts. They are often inconsistent historians and may seek evaluation by many physicians concurrently. These patients may also display evidence of mood disturbance such as depression or prominent anxiety symptoms, antisocial behavior, suicidal ideation, and interpersonal problems

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Undifferentiated Somatoform Disorder

This is a residual category for persistent somatoform presentations that do not meet full criteria for one of the specific somatoform disorders

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Undifferentiated Somatoform Disorder essential feature

The essential feature of this disorder is one or more physical complaints persisting for at least 6 mo. Frequent complaints include chronic fatigue, loss of appetite, and gastrointestinal or genitourinary symptoms
that cannot be explained by a general medical condition or a
substance, and are often excessive in nature

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Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion A

One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints)

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Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion B

Either (1) or (2):
1. After appropriate investigation, the symptoms cannot be fully explained by known general medical condition or
direct effects of a substance (e.g., a drug of abuse or medication).
2. When there is a related general medical condition, the physical complaints or resulting social or occupational
impairment are in excess of what would be expected from the history, physical examination, or laboratory findings

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Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion C

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning

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Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion D

The duration of the disturbance is at least 6 mo

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Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion E

The disturbance is not better accounted for by another mental disorder (e.g., another somatoform disorder, sexual
dysfunction, mood disorder, anxiety disorder, sleep disorder, or psychotic disorder)

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Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion F

The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering)

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Diagnostic Criteria for Conversion Disorder Criterion A

One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other
general medical condition. Motor symptoms or deficits include impaired coordination or balance, paralysis, aphonia, dysphagia, and urinary retention. Sensory symptoms include loss of touch or pain
sensation, diplopia, blindness, deafness, and hallucinations.
Symptoms may also include seizures or convulsions

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Diagnostic Criteria for Conversion Disorder Criterion B

Psychological factors are judged to be associated with symptom or deficit because the initiation or exacerbation of the
symptom or deficit is preceded by conflicts or other stressors

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Diagnostic Criteria for Conversion Disorder Criterion C

The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering)

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Diagnostic Criteria for Conversion Disorder Criterion D

The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by
the direct effects of a substance, or as a culturally sanctioned behavior or experience

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Diagnostic Criteria for Conversion Disorder Criterion E

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning or warrants medical evaluation

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Diagnostic Criteria for Conversion Disorder Criterion F

The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of
somatization disorder, and is not better accounted for by another mental disorder

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diagnosis of conversion disorder

should only be made after a thorough medical investigation has been performed to rule out
an etiologic, neurologic, or general medical condition. Because a general medical etiology for an apparent diagnosis of conversion disorder may take years to manifest, it is important to re-evaluate this diagnosis periodically.

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Relationship between conversion disorder and somatization disorder

Women presenting with conversion symptoms may eventually progress to meeting criteria for somatization disorder.

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Pain Disorder

The essential feature of pain disorder is pain that is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention

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Diagnostic Criteria for Pain Disorder Criterion A and B

Criterion A
The pain causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
Criterion B
Psychological factors are judged to have an
important role in the onset, severity, exacerbation,
or maintenance of the pain

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Diagnostic Criteria for Pain Disorder Criterion C and D

Criterion C
The symptom or deficit is not intentionally
produced or feigned.
Criterion D
The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia

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Common to both factitious disorder and malingering
(Criterion A)

is the intentional production of physical and/or psychological
symptoms

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Factitious Disorder

the motivation is the psychological need to assume the sick role (Criterion B); external incentives for the patient’s behavior (e.g., financial gain, avoiding work duties, obtaining opioid medications) should be absent (Criterion C).
Patients may complain about nonexistent symptoms,
create objective signs (e.g., warming skin to create erythema, using psychoactive drugs to suggest a mental disorder), or exaggerate symptoms of a previous diagnosis.

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Components of the history suggesting diagnosis of Factitious Disorder include the following:

multiple hospital admissions or
office visits, knowledge of medical terminology, vague and unverifiable history, chronic illness at a young age, difficulty
with interpersonal relationships and few visitors in the inpatient setting, comorbid personality disorders, or substance abuse disorder

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Malingering

the intentional falsification of physical and/or psychological symptoms is motivated by external factors (e.g., economic gain, avoiding legal responsibility, avoiding military service, or avoiding domestic duties

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Clues that suggest a diagnosis of malingering include

medico-legal context of the presentation, marked discrepancy between claimed stress or disability and objective findings, lack of cooperation during the diagnostic evaluation, and the presence of antisocial personality disorder

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Three types of malingering

In pure malingering,
patients fabricate symptoms that do not exist at all.
In partial malingering, symptoms that do exist are exaggerated.
Lastly, in false imputation, patients attempt to blame real symptoms on an unrelated event

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“malingering by proxy”

a parent fabricating an illness in his or her child, again for the purpose of external gain (such as social benefits)

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Successful identification of the malingering patient remains difficult. Waddell’s Signs maybe useful

Category: Signs
Tenderness: Superficial: light pinching causing pain = positive
Nonanatomic: deep tenderness over a wide area= positive
Simulation: Axial loading: downward pressure on the head causing low back pain = positive
Rotation: examiner holds shoulders and hips in the same plane and rotates patient; pain= positive
Distraction: Straight leg raise causes pain when formally
tested, but straightening the leg with hip flexed 90° to check Babinski does not
Regional: Weakness: multiple muscles not enervated by the
same root. Sensation: glove and stocking loss of sensation
Overreaction: Excessive show of emotion

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in the absence of objective
evidence of malingering what should be done

psychological testing such as
the Minnesota Multiphasic Personality Disorder, ed 2
or the Symptom Checklist-90-Revision can be helpful
in detecting exaggerations and inconsistencies in a history

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Diagnostic Criteria for Hypochondriasis Criterion A

Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms

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Diagnostic Criteria for Hypochondriasis Criterion B

The preoccupation persists despite appropriate medical evaluation and reassurance

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Diagnostic Criteria for Hypochondriasis Criterion C

The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern
about appearance (as in body dysmorphic disorder)

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Diagnostic Criteria for Hypochondriasis Criterion D

The preoccupation causes clinically significant distress
or impairment in social, occupational, or other important areas of functioning

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Diagnostic Criteria for Hypochondriasis Criterion E

The duration of the disturbance is at least 6 mo.

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Diagnostic Criteria for Hypochondriasis Criterion F

The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder

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Treatment of hypochondriasis

Treatment of hypochondriasis is difficult. Education, cognitive therapy, and behavioral therapy
offer the best chance of remission. Frequent medical
exams and benign therapies (heat, bracing, etc.) can be
helpful. There may also be a role for selective serotonin
reuptake inhibitors (SSRIs) in some patients.

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Diagnostic Criteria for Dyspareunia

Criterion A
Recurrent or persistent genital pain associated with sexual intercourse in either man or woman.
Criterion B
The disturbance causes marked distress or
interpersonal difficulty.
Criterion C
The disturbance is not caused exclusively by vaginismus of lack of lubrication, is not better
accounted for by another Axis I disorder (except another sexual dysfunction), and is not due
exclusively to the direct physiologic effects of a
substance (e.g., a drug of abuse or medication) or a general medical condition

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Diagnostic Criteria for Vaginismus

Criterion
A Recurrent or persistent involuntary spasm of the
musculature of the outer third of the vagina that interferes with sexual intercourse.
Criterion B
The disturbance causes marked distress or interpersonal difficulty.
Criterion C
The disturbance is not better accounted for by another Axis I disorder (e.g., somatization disorder) and is not due exclusively to the direct physiologic effects of a general medical condition

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Treatments for Vaginismus

pelvic floor control exercises, insertion or dilation training, and addressing the emotional component of the disorder

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