Somatic Symptoms and Related Disorders

Question 1

Types of DSM-V (2013) Somatoform Disorders 4

Answer 1

1. Somatic symptom disorder
2. Conversion disorder
3. Illness anxiety disorder
4. Other specified somatic symptom and related disorder.

Question 2

DSM IV (1994)

Answer 2

1. Somatization disorder
2. Hypochondriasis
3. Conversion Disorder
4. Pain Disorder
5. Body Dysmorphic Disorder
6. Undifferentiated Somatoform Disorder
7. Somatoform Disorder NOS

Question 3

Somatic Symptom Disorder is defined as?

Answer 3

A. One or more 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 one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. 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).

• Specify if: With predominant pain (previously pain disorder)
• Specify if: Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).
• Specify current severity: mild, moderate, or severe.

Question 4

SOMATIC SYMTPOM DISORDER Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: 3

Answer 4

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.

Question 5

SOMATIC SYMTPOM DISORDER Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). What things do you have to specify?

Answer 5

1. Specify if: With predominant pain (previously pain disorder)
2. Specify if: Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).
3. Specify current severity: mild, moderate, or severe.

Question 6

Somatoform symptoms 4

Answer 6

1. Symptoms suggest a physical disorder
2. Symptoms cannot adequately be explained physiologically
3. Symptoms are often (but not always) described in dramatic ways 4. Other disorders, such as anxiety disorders, mood disorders, and personality disorders, often co-exist

Question 7

Characteristics of the somatoform patient? 4

Answer 7

1. Not improving
2. Pain everywhere
3. Your most difficult pt
4. Come in every day

Question 8

Characteristics of Somatization Disorder? 4

Treatment? 3

Causes? 3

Answer 8

Question 9

Physical symtpoms of somatoform disorder

Answer 9

Question 10

1. Age of onset?
2. HOw will lit present in Kids?
3. Course?
4. Culture: cultural influences appear to affect what?
5. Symptoms vary across cultures. examples?
6. Lower levels of somatization d/o with what?

Answer 10

1. older…natural aging
2. tummy aches (do we teach them?)
3. Chronic, rarely cured
4. Culture: cultural influences appear to affect the gender ratios and body locations of somatoform d/o (Greek and Puerto Rican cultures report higher rates among men than is the case for the US)
5. Symptoms vary across cultures (e.g. burning hands and feet, “worms in the head”, “ants under the skin” much more common in Africa and South Asia)
6. Lower levels of somatization d/o with higher education levels

Question 11

Pathopysiology of somatoform disorder?

Answer 11

Need to be sick!

Becoming physically sick is less stressfull than being unsuccessfull

“There is no medicine or

surgery to remove the

need to be sick”

Question 12

Somatization Disorder: Causes? 3

Answer 12

Causes

1. Family history of illness
2. Relation with antisocial personality disorder
3. Weak behavioral inhibition system

Question 13

Somatic Symptom Disorder: Treatment? 4

Answer 13

1. No treatment proves superior effectiveness
2. However, we need to reduce visits to numerous medical specialists
3. Assign one main Primary Care Provider
4. Reduce supportive consequences of talk about symptoms

Question 14

Things to focus on and manage with patients that have somatoform?

4

Answer 14

1. Allow patient role
2. Concentrate on functions
3. Frequent, short visits
4. Single provider

Question 15

1. Conversion Disorder is what?
2. Onset, reappearance, termination of disease?
3. Mostly found in who? 2

Answer 15

1. Physical symptoms suggesting neurological problems
   - Sensory impairment: Any modality
   - Paresthesias, blindness, paralysis
2. Sudden onset, sudden termination, sudden reappearance
3. Mostly women; men in combat

Often misdiagnosed

La belle indifference: 1/3 of cases

Question 16

Facts about Conversion Disorder

1. Age of onset?
2. Course?
3. Culture: Found in who commonly? 3

Answer 16

1. Age of Onset: Late childhood- early adulthood rarely before 10 or after 35
2. Course: Onset acute or sudden, symptoms remit after about 2 weeks, but recur approximately 25% of the time
3. Culture:
   - More common in rural areas,
   - lower SES, and
   - lower educational levels

Question 17

Conversion Disorder…criteria

6

Answer 17

A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a Neurological or other General Medical Condition

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

C. The symptom or deficit is not intentionally feigned (as in Factitious Disorder or Malingering)

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

E. The symptom or deficit causes clinically significant distress or impairment in functioning

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

Question 18

Characteristics of Conversion Disorders? 4

Treatment? 2

Causes? 3

Answer 18

Question 19

Conversion Disorder: Causes

4

Answer 19

Causes

1. Freudian psychodynamic view is still popular
2. Focus on past trauma and conversion
3. Address primary and secondary gain
4. Detachment from the trauma

Question 20

Conversion Disorder: Treatment

4

Answer 20

1. Similar to somatization disorder
2. Core strategy is attending to the trauma
3. Remove success of secondary gain
4. Reduce supportive consequences of talk about symptoms

Question 21

Illness Anxiety Disorder

1. What isn’t necessary for Dx?
2. Why do they have severe anxiety?
3. Preoccupied with what feelings?
4. Interactions with providers? 2
5. What do they overly report?

Answer 21

1. No physical symptoms are necessary
2. Severe anxiety- the possibility of having a disease
3. Preoccupied with the possibility that normal sensations are symptoms of serious disease

4.

• Frequent visits to providers
• Persists despite medical reassurance
  5. Over-report bodily sensations

Question 22

Illness Anxiety Disorder

Criteria?

6

Answer 22

1. Preoccupation with having or acquiring a serious illness.
2. Somatic symptoms are not present or, if present, are only mild in intensity.
3. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
4. The individual performs excessive health related behaviors or exhibits maladaptive avoidance.
5. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over time.
6. The illness-related preoccupation is not better explained by another mental disorder.

Question 23

Facts about Illness Anxiety Disorder

1. Gender?
2. Age of onset?
3. Course?
4. Assocations?5

Answer 23

1. Gender: Equal
2. Age of Onset: any age, most common early adult
3. Course: Chronic, but waxes and wanes
4. Associations:
   - Fears of aging and death,
   - “doctor shopping”,
   - poor relationships with providers,
   - past experience with disease,
   - family and work problems

Question 24

Illness Anxiety Disorder

Main Characteristic? 4

Answer 24

1. “Disease of having disease”
2. Severe anxiety
3. No insight
4. Resistant, causing functional losses

Question 25

Illness Anxiety Disorder: 1. Causes 2 2. Treatment 2

Answer 25

1. Causes - Cognitive perceptual distortions - Familial history of illness 2. Treatment - Challenge illness-related misinterpretations - Provide more substantial and sensitive reassurance

Question 26

Biological factors that might contribute to Illness Anxiety Disorder? 3

Answer 26

1. One sign (objective indicator) of anxiety is an increased level of cortisol, a stress hormone. Cortisol levels are elevated in patients with somatization disorder. 2. But there is no concordance in twin studies for any somatoform disorder. 3. The right hemisphere may be implicated in conversion disorder, symptoms of which are more likely in the left half of the body. The right hemisphere is involved in emotional experience and expression.

Question 27

Describe the cycle for Illness Anxiety Disorder 6 steps in the cycle

Answer 27

Question 28

Other Specified Somatic Symptom and Related Disorder (DSM V) 4

Answer 28

1. Brief somatic symptom disorder: less than 6 months. 2. Brief illness anxiety disorder: less than 6 months. 3. Illness anxiety disorder without excessive health-related behaviors: Criteria D for illness anxiety disorder is not met. 4. Pseudocyesis: False belief you are pregnant.

Question 29

Unspecified Somatic Symptom and Related Disorder 1. Characterized as? 2. Don't use unless what?

Answer 29

1. They definitely cause distress…..but don’t fit anywhere else. 2. Don’t use unless there are decidedly unusual situations where there is insufficient information to make a more specific diagnosis

Question 30

Somatoform Disorder NOS 2

Answer 30

1. Pseudocyesis (False Pregnancy)….all the s/s of pregnancy except for the presence of a fetus 2. Hypochondriacal symptoms less than 6 months

Question 31

Etiology of somatoform disorders 2

Answer 31

1. Psychoanalytic theory 2. Behavior theory

Question 32

Etiology of somatoform disorders 1. Psychoanalytic theory: two specific etiologies in this category? 2. Behavior theory: Three specific etiologies in this category? 3

Answer 32

Psychoanalytic theory 1. Controlling repressed sexual urges - Displaced anxiety or secondary gain 2. Sackeim: Deny knowledge but use information Behavior theory 1. Malingering 2. Social learning and reinforcement 3. Secondary gain

Question 33

Body Dysmorphic Disorder Shifted to what in the DSM-V?

Answer 33

Previously described in DSM III as a somatoform d/o DSM V…. shifted to the obsessive compulsive spectrum

Question 34

Body Dysmorphic Disorder Characteristics? 3

Answer 34

1. Excessive concern with real or imagined defects in appearance, especially facial marks or features. 2. Frequent visits to plastic surgeons 3. May be a symptom of more pervasive disorders: Obsessive-compulsive or delusional disorder, for example.

Question 35

Body Dysmorphic Disorder Criteria? 5

Answer 35

1. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. 2. The preoccupation causes clinically significant distress or impairment in functioning 3. The preoccupation is not better accounted for by another mental disorder 4. Either fixation with or avoidance of mirrors 5. Suicidal ideation and suicidal behavior are common

Question 36

Facts about Body Dysmorphic Disorder 1. Gender? 2. Age of onset? 3. Course? 4. Associations? 5

Answer 36

1. Gender: Equally common in men and women 2. Age of Onset: Usually starts in adolescence 3. Course: Chronic 4. Associations: - Excessive checking/grooming, - removal of mirrors, - social isolation, - surgical procedures, - suicide Probably greatly underdiagnosed

Question 37

1. Body Dysmorphic Disorder: Causes? 5 2. Treatment? 4

Answer 37

Unknown, likely intricate through an interaction of multiple factors 1. Genetic 2. Developmental 3. Psychosocial 4. Social 5. cultural Shares similarities with OCD Treatment 1. Parallels that for OCD 2. CBT 3. SSRIs may provide relief 4. Plastic surgery is not helpful

Question 38

What is very important to have when treating a somatoform disorder?

Answer 38

Pain contracts are very important

Question 39

How can you differenciate a real seizure from a pseudoseizure?

Answer 39

prolactin levels

Question 40

Whats the differenece between malingering and factitious disorder? 2

Answer 40

malingering- exaggerate or feign illness in order to escape duty or work/has a secondary gain Factitious disorder- intrinsic- no secondary gain

Question 41

This patient is malingering (feigning medical illness motivated by secondary gain) You can suspect it just based on the story but there are a couple of major tipoffs? 3

Answer 41

1. Memory loss following head injury is unusual without LOC, and typically the amnesia would involve the accident and events surrounding the accident 2. Long-term memories are LEAST likely to be affected by mild traumatic injury 3. Loss of orientation to person without other memory deficits seldom occurs

Question 42

What is the difference between OCD and OCPD? 3

Answer 42

1. OCPD is associated with chronic, pervasive personality traits such as rigidity, perfectionism, and orderliness but lacks true obsessions and compulsions present in OCD 2. Patients with OCPD do not feel their actions are inconsistent with their overall personality 3. Patients with OCD report that their actions are foreign and distressing

Question 43

Both are CNS stimulants and so there is much overlap. However, the following is more likely to be seen in amphetamine abuse:

Answer 43

1. Psychosis symptoms: paranoia, agitation, visual hallucinations 2. Dental issues “meth mouth”: bruxism (teeth-grinding), dental erosion from acidity of methamphetamine fumes