BH E3- Somatic Symptoms & Disorders

What are conditions in which psychological conflicts are translated into physical problems, which impairs function & causes distress?

**symptoms NOT confirmed on physical or neurological tests

Somatic disorders

What is the MC population for somatic disorders?

F > M

What is the etiology of somatic disorders?

Pain threshold, emotional pain that translate into physical pain, pain in order to escape from dislike of activity, pain to stabilize relationships

What clues might suggest somatic disorders?

Excessive or chronic pain, chronic multiple sx w/o adequate explanation or no correlation, sx don’t improve despite treatment, & excessive concern with health

What is the classical clinical pattern of somatic symptom disorder?

Hx of multiple evaluation of sx which leads to → unnecessary, ineffective expensive or dangerous treatment

What is a disorder in which an individual experiences high levels of anxiety & persistent worry about bodily signs and symptoms that are misinterpreted as having a known medical disorder?

Somatic symptom disorder

The following key features are associated with what condition?

• pt believes they have serious dz that has not yet been detected & cannot be persuaded to believe otherwise

• complaints of multiple physical sx (pain, heart, GI, pulm, etc)

Somatic symptom disorder

The following criteria is associated with what condition?

• ≥1 somatic symptom (may be predominantly pain) that are distressing or result in significant disruption

• excessive thoughts, feelings, or behaviors related to sx or health concerns

• sx persist for atleast 6 mos

Somatic symptom disorder

How long to episodes last in somatic symptom disorder?

Months-years

What is the treatment for somatic symptom disorder?

Regularly scheduled PCP visits (4-8 wks) & discuss overall health, SSRIs to tx cormorbid anxiety & depression symptoms, refer to psych if refractory

What factors are associated with a good prognosis in somatic symptom disorder?

Sudden onset, short course of sx, treatment responsive anxiety or depression, absence of personality disorder

What should be done at the initial visit with somatic symptom disorder?

Establish therapeutic alliance → legitimize sx, eval & tx diagnosable medical conditions, limit tests & referrals, reassure, pt education, slow d/c unnecessary meds

What is a disorder in which a person has a preoccupation with and fear of having/acquiring a serious illness?

*formerly called hypochondriasis

Illness anxiety disorder

What condition?

• symptoms (abd pain, D, etc) → severe emotional distress → multiple doctors visits → impairment in functioning → progression into depression & long term anxiety disorder

Somatic symptom disorder

What condition?

• minimal or nonexistent sx → preoccupation of being sick or having disease → extreme anxiety, distress & out of proportion belief of worst possible outcome

• ex: thinking a HA is a brain tumor; may seek or avoid care

Illness anxiety disorder

The following criteria is associated with what condition?

• preoccupation with having or acquiring serious illness

• high level of anxiety about health

• performs excessive health related behaviors or exhibits maladaptive behaviors

• +/- somatic sx

• behavior persists at least 6 mos

Illness anxiety disorder

What clues might indicate illness anxiety disorder?

Multiple doctor visits & medical tests (watch for same complaint), repetitive checking of body for sx of alleged medical condition, habitual internet searching about illness or sx (cyberchondria)

When does illness anxiety disorder MC onset?

~30-60 y/o

*sx wax & wane, chronic episodic course, most improve w tx

What is the treatment for illness anxiety disorder?

1st line: regular PCP visits, CBT

2nd line: regular PCP visits, CTB, antidepressants

3rd line: regular PCP visits, antidepressants, refer psych

What SSRIs are used to treat illness anxiety disorder?

Fluoxetine or paroxetine

*switch in 6 weeks if no clinical response

What is a disorder in which an individual “converts” psychological distress into an actual neurological symptom?

*formerly conversion disorder

Functional neurological symptom disorder

The following key features are associated with what condition?

• at least 1 neuro sx (sensory or motor)

• sx can’t be fully explained by a neuro condition on exam

• pts appear calm & unconcerned when describing sx (la belle indifference)

• ex- anxiety over expected work performance → sudden blindness

Functional neurological symptom disorder

The following criteria is associated with what condition?

• at least 1 sx of altered voluntary or motor sensory function

• evidence of incompatibility bt sx and recognized neurological or medical conditions on exam

• no other medical disorder causing the sx

• distress and impairment in functioning that warrants medical evaluation

Functional neurological symptom disorder

What is the course of functional neurological symptom disorder?

Acute onset, sx may progress with time & most spontaneously remit in 2 weeks with tx

What factors are associated with a poor prognosis in functional neurological symptom disorder?

Symptoms of tremors or seizures

*< 50% improvement if sx persist past 6 mos

What factors are associated with a good prognosis in functional neurological symptom disorder?

Acute onset, clearly identifiable stressors at time of onset, early treatment, & presence of paralysis, mutism and blindness

What is the treatment for functional neurological symptom disorder?

1st line: patient education

2nd line: motor-PT & CBT; sensory- CBT & stress management

3rd line (refractory): Citalopram, duloxetine, or nortriptyline

What is a disorder in which an individual falsifies physical or psychological symptoms in order to receive medical care?

*formerly munchausen syndrome

Factitious disorder

The following key features are associated with what condition?

• deception

  • deliberate exaggeration or production of illness/ injury

• no other agenda other than medical attention

• goal is to assume role of sick pt

• may go to extreme measures that can cause legitimate danger

  • insulin injections, tampering with medical instruments, tests, lab specimens

Factitious disorder

What are red flags that might signal factitious disorder?

Unusual dramatic presentation of sx (pain scale does not correlate), no appropriate response to treatment, new unusual sx when other sx resolve, eagerness to undergo procedures or tests, multiple drug allergies, reluctance to give medical info, extensive medical history, ability to predict progression / response to treatment

The following criteria is associated with what condition?

• falsified physical or psychological ssx or induction of injury / disease

• deceptive behavior is evident even in absence of obvious external rewards → only desires medical attention

  • r/o malingering, which involves deception for external gain

Factitious disorder

The following presentations are likely to be associated with what disorder?

• burns: unnatural shape, chemical streaks, or minor injury to fingers → self inflicted

• cuts: accessible parts of body or preponderance of L sided lesions in R handed person → self inflicted

• thyroid: 24 hr I-131 uptake → thyroxine or l-iodothyronine

• etc

Factitious disorder

What population is factitious disorder MC in?

Hospital & health care workers; early adulthood onset

What are RF for factitious disorder?

Childhood abuse or abandonment, history of prior illness or hospitalization, personality disorders

What is a disorder in which an individual intentionally produces physical ssx in another person who is under their care (MC child or older adult)?

*formerly munchausen by proxy

Factitious disorder imposed on another

What is the etiology for factitious disorder imposed on another?

Desire for caretaker to indirectly assume sick role & be relieved fo caretaking role

What are individuals who falsify symptoms and illness to obtain external rewards such as money, time off work, & avoidance of duties?

Malingering

The following key features are associated with what condition?

• seek medical treatment in order to meet external agenda

• stops producing ssx when no longer profitable or when the risk becomes too great

• *not considered to be a mental illness

Malingering

What is Waddell’s sign?

Group of physical signs used to assess pain & psychological component → tenderness, stimulation, distraction tests, regional disturbances, overreaction