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Behavioral Dynamics > Somatoform Disorders* > Flashcards

Somatoform Disorders* Flashcards

1
Q

Physical symptoms that may not be fully explained by a known medical diagnosis after appropriate work-up

A

Somatization

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2
Q

Is somatization conscious or unconscious? What might influence a patient to develop somatization?

A

May be either but usually considered unconscious
Desire to be the patient or need for personal gain

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3
Q

Up to ___ of primary care patients display at least some degree of somatization. What percent of medical/surgical patients have no known organic cause for their symptoms?

A

25%, 10%

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4
Q

How is somatization related to biological disease?

A
  • Most patients have at least some degree of biologic disease
  • somatization is an over response to symptoms

Patients believe themselves more ill than objective evidence suggests

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5
Q

What are risk factors for somatization?

A
  • Female
  • Low socioeconomic status
  • Low education
  • Minority ethnicity
  • Family member with chronic illness
  • History of abuse or trauma
  • Comorbid psych disorder
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6
Q

What are causes of somatization

A
  • Provides social support
  • Rationalization for failures of roles
  • Means of obtaining nurturance
  • Cry for help
  • Psychological disorders incorrectly attributed to physical disease
  • Less stigmatized than psychiatric illness
  • Hypersensitive to somatic symptoms
  • Learned behavior
  • Provides incentives- disability, avoidance of social responsibility
  • Physical or sexual child abuse trauma response
  • Inadvertently physician influenced by symptomatic treatment of fashionable diseases
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7
Q

What term does the ICD-10 use for somatization? DSM-V-TR?

A

ICD-10: Somatoform disorders
DSM-V-TR: somatic symptom and related disorders

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8
Q

Syndrome of multiple unexplained physical symptoms

A

Somatic Symptom Disorder

Previously referred to as somatization disorder
In past, would have been diagnosed with hypochondria, pain disorder, and somatization disorder

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9
Q

What is the prevalence of somatic symptom disorder?

A

.1-.4%
Believed to be much higher, especially in hospitalized/surgical patients

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10
Q

What patient populations is somatic symptom disorder more common in?

A
  • Female
  • Unmarried
  • Non-white
  • Poorly educated
  • Rural area
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11
Q

What is the etiology of somatic symptom disorder?

A
  • Some genetic
  • Unstable, dysfunctional family common
  • Physical symptoms to cope with repressed psych symptoms
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12
Q

What is the classic presentation of somatic symptom disorder?

A
  • Multiple unexplained physical symptoms accompanied by sense of urgency
  • Complicated medical history
  • Multiple invasive diagnostic studies/procedures/treatments
  • Commonly affecting GI, reproductive, neuro
  • Symptoms: Pain, N/V/D, bloating, dizziness, dysphagia, SOB
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13
Q

What are the diagnostic criteria for somatic symptom disorder?

A
  • 1+ somatic symptom that causes distress or disruption
  • 1+ of the following: 1) disproportionate and persistent thoughts about seriousness of symptoms 2) persistent high level of anxiety about health/symptoms 3) excessive time and energy devoted to symptoms/health concerns
  • Symptoms for >6 months
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14
Q

Somatic symptom disorder with somatic symptoms mostly related to pain

A

Somatic symptom disorder with predominant pain

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15
Q

Somatic symptom disorder with severe symptoms, marked impairment, and long duration

A

Persistent somatic symptom disorder

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16
Q

How can the severity of somatic symptom disorder be described?

A

Mild: 1 symptom
Moderate: 2+ symptoms
severe: 2+ symptoms plus multiple somatic complaints

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17
Q

what questionnaire can be used to assess for somatic symptom disorder?

A

Somatic Symptom Scale-8

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18
Q

How is somatic symptom disorder treated?

A
  • Care through one PCP with frequent, routine follow-ups
  • Avoid new or excess diagnostic studies
  • No specific pharmaceutical management, treat comorbid disorders
  • Psychotherapy- can reduce health expenditures by 50%
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19
Q

Previously referred to as conversion disorder, marked by altered voluntary motor or sensory function

A

Functional Neurological Symptom Disorder

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20
Q

What is the prevalence of functional neurological symptom disorder?

A

1-3% neurology patients
33% women
5-10% hospitalized/surgical patients referred to psych

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21
Q

What age most commonly gets functional neurological symptom disorder?

A

10-35 yo

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22
Q

what are the risk factors of functional neurological symptom disorder?

A
  • Trauma (may trigger)
  • Comorbid psych disorders
  • Lower IQ, less educated/socially sophisticated
  • Delayed verbal communication/impaired ability to articular distress
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23
Q

What is the classic presentation of functional neurological symptom disorder?

A
  • Neurological symptom (s) that do not correlate with the presence of organic disease
  • Often inconsistent or incongruent
  • Hoover’s sign
  • Common symptoms: pseudoseizures, paralysis, blindness, mutism, paresthesia, anesthesia
  • Episodic, recur with stress

Sensory, motor, or both

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24
Q

What is Hoover’s sign?

A

weakness with hip extension that becomes strong when contralateral leg is flexed

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25
Q

How is Functional Neurological Symptom Disorder diagnosed?

A

1+ symptoms affecting voluntary motor or sensory function
Symptoms incompatible with neurological or medical condition

Not better explained by another condition and causes significant distress or impairs functions

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26
Q

What differential diagnosis should be considered for functional neurological symptom disorder?

A

other psych disease
neurological disease
malingering

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27
Q

What is treatment of functional neurological symptom disorder?

A
  1. Education about disorder
  2. Psychotherapy referral

Education: symptoms often resolve spontaneously, reversal of symptoms possible, treat comorbid psych diagnoses
Psychotherapy: insight-oriented or behavioral therapy

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28
Q

Condition characterized by preoccupation with a serious illness with minimal to no somatic symptoms to support this concern

`

A

Illness Anxiety Disorder

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29
Q

What is the prevalence of illness anxiety disorder?

A

2-7% of ambulatory patients

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30
Q

What gender/age is most common for illness anxiety disorder?

A
  • equally common in men and women
  • MC onset age 20-30
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31
Q

What is the etiology of illness anxiety disorder?

A
  • Unknown, no evidence of genetic
  • Low thresholds of physical discomfort
  • Learned behaviors about illness and symptoms
  • Often comorbid with anxiety disorders and/or depressive disorders
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32
Q

What is the classic presentation of illness anxiety disorder?

A
  • Misinterpretation of benign symptoms
  • Extremely detailed histories
  • Fixed on one disease or move to new disease over time
  • Symptoms wax/wane with stress
  • Unswayed by negative objective findings
33
Q

What is the criteria for diagnosis of illness anxiety disorder?

A
  1. Preoccupation with having or getting serious illness
  2. Somatic symptoms mild/not present or preoccupation with condition excessive and disproportionate
  3. High anxiety and easily alarmed about health status
  4. Excessive health related behaviors/maladaptive avoidance
  5. Symptoms >6 months
  6. Not better explained by another mental disorder

Excessive health related behaviors or maladaptive avoidance: repeatedly checks body for signs or avoids appointments and hospitals

34
Q

What differential diagnosis should be considered for illness anxiety disorder?

A
  • OCD
  • Anxiety disorders
  • Other somatoform disorders
  • Acute medical conditions
35
Q

How is illness anxiety disorder treated?

A
  • Frequent, regular visits
  • Compassionate, tactful education on illness
  • Diagnostic studies only with objective evidence
  • Therapy if patients willing
  • Medications for comorbid conditions

Patients often decline psychiatric referral

36
Q

Condition characterized by preoccupations with perceived appearance defects

A

Body dysmorphic disorder

37
Q

What is the prevalence of body dysmorphic disorder?

A
  • 1-5%
  • Most seen at dermatology or plastic surgery
38
Q

Which age/gender more commonly has body dysmorphic disorder?

A
  • Equal male and female
  • 20-40 years old, many unmarried
39
Q

Etiology of body dysmorphic disorder

A
  • No evidence of genetic
  • Related to OCD
  • Association with social anxiety disorder and major depressive disorder
40
Q

Classic presentation of body dysmorphic disorder

A
  • Preoccupation with specific aspect of appearance
  • May be vague, imperceptible to others, hard to understand
  • Concern may change over time
  • Believe others notice more than they do
  • Excessively check mirrors or avoid
  • Attempt to hide deformity
41
Q

Almost all patients with body dysmorphic disorder _____

A

Avoid public exposure/interaction
* 1/3 totally housebound
* 1/5 attempt suicide

42
Q

What are common problem areas of patients with body dysmorphic disorder?

A
  • Facial features
  • hair
  • breasts
  • genitalia
43
Q

What is criteria for body dysmorphic disorder?

A
  • Preoccupation with 1+ perceived defect/flaw in physical appearance
  • Repetitive behaviors or mental acts

Causes distress or functional impairment and not better accounted for by another mental disorder

44
Q

What are common repetitive behaviors and mental acts performed by patients with body dysmorphic disorder?

A

Behaviors: mirror checking, excessive grooming, skin picking, reassurance seeking
Mental acts: comparing appearance to others

45
Q

Body dysmorphic disorder with idea that muscle mass is too small

A

with muscle dymorphia

46
Q

What are insight specifiers for patients with body dysmorphic disorder?

A
  • Good or fair insight- believes disordered beliefs are not true
  • Poor insight- believes beliefs probably true
  • Absent insight/delusional beliefs- completely convinced BDD beliefs true
47
Q

How is body dysmorphic disorder treated?

A
  • Correction of perceived flaw almost never helpful!
  • SSRIs = first line pharm
  • Psychotherapy = CBT, cognitive restructuring with exposure therapy
48
Q

How is somatic symptom disorder with predominant pain categorized?

A

Based on associated factors
* Psychological
* General medical condition
* Psychological factors and general medical condition

Most patients have some degree of physical disease that causes pain, but response is abnormal

49
Q

What is the prevalence of somatic symptom with predominant pain

A

MC somatoform disorder
* 8.1% 12 month
* 12.7% lifetime

50
Q

What gender/age is somatic symptom disorder with predominant pain most common?

A
  • MC women
  • More common older (40-50)
51
Q

What is the etiology of somatic symptom disorder with predominant pain?

A
  • No genetic predisposition
  • Somatic expression of depression
  • Relation to guilt- deserving pain
52
Q

Classic presentation of somatic symptom disorder with predominant pain

A

Focus on symptom of pain in 1+ areas
* Varying types of pain
* Long history of medical and surgical care
* May deny other sources of negative emotion

May have medical condition, but psych factors play major role

Not intentionally produced or feigned

53
Q

What is DSM criteria of somatic symptom disorder with predominant pain?

A
  • 1+ somatic symptom predominantly involving pain, causes distress or disruption
  • Excessive thoughts, feelings or behaviors related to somatic symptom
  • Symptoms >6 months
54
Q

What are manifestations of excessive thoughts, feelings or behaviors in somatic symptom disorder with predominant pain according to DSM?

Must have 1+ of following with somatic symptom

A
  1. Disproportionate and persistent thoughts about symptoms
  2. Anxiety about health/symptoms
  3. Excessive time/energy devoted to health concerns
55
Q

What is the treatment of somatic symptom disorder with predominant pain?

A
  • Alleviation of underlying psych symptoms/environmental factors
  • May have opiate addiction/dependence
  • NSAIDs first line if analgesics needed
  • Psych meds: antidepressants–> SNRIs > SSRIs, TCAs also useful

Avoid opioids

56
Q

Intentionally faking symptoms to assume patient role

A

Factitious disorder

57
Q

General diagnosis to describe when psych or behavioral factors have a significant impact on a medical illness

A

Psychological factors affecting other medical disorders

58
Q

What are general guidelines for treatment of somatic disorders?

A

Relationship with PCP and management of complaints

59
Q

What are guidelines for PCP communicating with somatic conditions?

A
  • Schedule regular visits
  • Acknowledge and legitimize symptoms
  • Reassure medical conditions are ruled out
  • Educate on coping with physical symptoms
60
Q

How should complaints of somatic disorder patients be managed?

A
  • Communicate with other providers
  • Evaluate and treat diagnosable disease
  • Limit diagnostic testing and referrals
  • Consider psychotherapy
  • Treat comorbid psych disorders/substance abuse
  • Goal of treatment = functional improvement
  • Pharmacotherapy with SSRIs, SNRIs, TCAs
61
Q

Condition characterized by intentional faking of s/s to appear ill, impaired, or injured

Persists without obvious rewards, motivation is assume sick role

A

Factitious disorder

62
Q

Former name for factitious disorder

A

Munchausen syndrome

63
Q

Intentional induction of symptoms on a victim other than the patient with the disorder

This is form of abuse! Usually severe

A

Munchausen syndrome by proxy

May be referred to as factitious disorder by proxy

64
Q

What is the prevalence of factitious disorder?

A

General clinical population = 1%
Psychiatric inpatients = 8%

65
Q

What are risk factors for factitious disorder?

A
  • Female
  • Unmarried
  • Healthcare workers
  • Childhood abuse

Munchausen syndrome- male

66
Q

Former name for factitious disorder still used to refer to especially severe cases of factitious disorder

A

Munchausen syndrome

67
Q

Classic presentation of factitious disorder

A
  • Psychological or physcial s/s of illness
  • Different accounts of illness to different clinicians
  • Evasive about history, may refuse to share records
  • Seen at multiple facilities by multiple providers
68
Q

How might a patient with factitious disorder cause s/s?

A
  • Misuse of medication
  • Inferfering with tests
  • Coaching others to correlate history
  • Nonadherence to care plans of existing illness
  • Self-inflicting injuries
  • Forging medical records
69
Q

What is the DSM criteria of factitious disorder?

A
  • Single episode or recurrent
  • Falsification of physical/psychological s/s
  • Present as ill, impaired, or injured
  • Deceptive behavior even in absence of rewards

Not better explained by another mental disorder

70
Q

What are common symptoms of factitious disorder?

A
  • Poor wound healing, pain, seizures, hypoglycemia, GI symptoms, depression, suicidal thoughts
71
Q

Patients with factitious disorder often agree to ______ but are strongly adverse to ______
They usually have _____ and symptoms may be ______

A

complex work-ups, specialty consults, and invasive procedures
psychiatric consult
few visitors in hospital
unusual or rare

72
Q

In the severe form of factitious disorder, patients do what?

A
  • Have aliases and wander from clinic to clinic
  • Present on night/weekends with dramatic/severe symptoms, extraordinary history, and inconsistent findings
  • Fail to respond to standard treatment
  • Become upset or angry when confronted
73
Q

What is the classic presentation of factitious disorder imposed on another?

A
  • Mother inflicting symptoms of illness onto child
74
Q

What are clues to diagnosis of factitious disorder imposed on another?

A
  • Incongruent history
  • Recurrent, unexplained, prolonged, unusual illness
  • Limited/no response to standard therapy
  • S/s worsen when victim around perp or when about to be discharged
  • S/s improve when victim not around perp, lack of concern over health, agreeable to invasive procedures
  • Caregiver closely involved with care team
75
Q

How is factitious disorder treated?

A
  • Single provider to coordinate care
  • Psychotherapy
  • Tx of comorbid psych disorders
  • By proxy- must be reported, criminal act, involve social work/protective agencies
76
Q

Condition characterized by intentional faking of s/s to appear ill, impaired, or injured

A

Malingering

77
Q

How is malingering different from factitious disorder?

A
  • Secondary motivation
  • Often avoid excessive procedures, especially painful or invasive ones
78
Q

What is the prevalence of malingering?

A

Unknown
* Study found up to 20% patients in pain clinic

79
Q

How is malingering treated?

A
  • Avoid being manipulated by patient for secondary goal
  • Treat underlying medical conditions

Difficult due to patient denial of malingering

Behavioral Dynamics (6 decks)

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