clin med M13 Somatic symptom disorders & preventative healthcare:

what are the 3 somatic symptom disorders?

• Illness anxiety disorder

• Somatic symptom disorder

• Functional neurological symptom disorder 

illness anxiety disorder:

1. Excessive preoccupation with possibility of illness or symptoms 

   • Symptoms typically absent or mild at the time of the encounter 

2. High level of anxiety with health related topics & worry about developing symptoms in the future 

3. Increased self examination or obsessive online research 

4. Symptoms present for ≥6 months

illness anxiety disorder key differentiators:

excessive worry about having a serious illness with little to no sxs

• Ex: terrified about the prospect of breast CA so doing several breast checks each day 

• Previously called “hypochondria”

1st line tx for illness anxiety disorder:

CBT

2nd line treatment for illness anxiety disorder:

SSRIs

• prozac

somatic symptom disorder:

1. ≥ 1 physical symptom that causes either distress or functional impairment

2. ≥ 1 abnormal thought or behavior 

   • Excessive & pervasive thoughts about sxs

   • Persistently ↑anxiety about health 

   • Excessive time spent addressing sxs

3. Symptoms present for ≥6 months 

s/s of somatic symptom disorder:

• Focal weakness

• GI distress

• Fatigue

• Pain 

• Abnormal thoughts (excessive worry or obsession)

• Abnormal behaviors (frequent self examination or frequency ER visits)

  • Or avoidance of appointments due to anxiety

tx for somatic symptom disorder:

• Regular follow-up w PCP q4-8 weeks

  • +/- psychotherapy

what is functional neurologic disorder?

1. ≥ 1 symptom involving involuntary motor or sensory function:

• Voluntary muscle dysfunction:

  • Tremor

  • Weakness

  • Paralysis

  • Gait disturbance

  • Seizure-like limb movements

• Sensory dysfunction:

  • Numbness

  • Paresthesia

  • Visual changes

  • Hearing loss

  • Change to taste or smell 

2. Evidence that sx are incompatible w other conditions 

   1. Symptom must cause distress or impairment

acute vs persistent functional neuro disorder:

Acute episodes: symptoms present for <6 months

Persistent: symptoms present for ≥6 months

for what condition may you see “La belle indifference”?

functional neurological disorder

what is la belle indifference?

• Pt may be too chill about what's going on 

  • EX: “the drs will figure it out eventually”

what is functional neurological disorder often related to?

stress

treatment for functional neurological disorder?

• Condition education

• CBT

• PT

• +/- OT & SLP

• 2nd line: Meds if comorbid mental illness

what is malingering?

When individuals are intentionally faking or exaggerating their symptoms in order to achieve some secondary gain or external goal

• May include: getting money, housing, time off from work, access to medications, escaping jail time

can malingering be imposed on someone else?

yes

Ex: mom did this to child to get out of work

clinical manifestations of malingering:

• Conscious of motivation

  • For reward!!

• Uncooperative

  • demand an extensive workup, but are not satisfied with negative results and don’t adhere to the diagnostic follow-up or treatment plan

• Not satisfied with negative results 

  • Symptoms stop once they achieve their goal

what is factitious disorder?

Individuals are intentionally faking or inducing symptoms, w the goal of getting attention and sympathy that is often given to someone who’s sick

who is factitious disorder MC in?

• those w HC experience

• females

clinical manifestations of factitious disorder:

• usually unconscious or unaware of their motivation, which means that individuals often don’t even realize why they fabricate their symptoms

  • pretend symptoms persist even after they get the attention, sympathy, or even medical care

factitious disorder imposed on self:

(Munchausen syndrome)

• Falsification on physical or psychological symptoms or induction of injury or disease, associated w identified deception 

• Pt presents themselves as ill, impaired, or injured 

  • The deceptive behavior is evident even in the absence of obvious external rewards

• Behavior not better explained by another mental disorder 

• individuals mainly pretend to have physical signs and symptoms of a disease

• these individuals typically have a medical record of recurrent hospitalizations, and are overeager to go through invasive interventions, like surgical procedures

factitious disorder imposed on another:

(Munchausen syndrome by proxy)

• Falsification of physical or psychological symptoms, or induction of injury or disease in another person, associated w identified deception 

• Individual -presents the victim (typically a dependent, such as a child or elder) to others as ill, impaired, or ill 

• The deceptive behavior is evident even in the absence of obvious external rewards 

• The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder 

  • The diagnosis is applied to the perpetrator, not the victim 

• person deliberately makes a second person ill without that person’s knowledge

• Often, the 2nd person is someone they’re responsible for, like a child, an elder, or even a pet

  • this is considered a type of child or elder abuse

how do u diagbose factitious disorder?

DSM-5

treatment of factitious disorder:

• pharmacotherapy 

Pts should be managed by one physician and have a close relationship w them

what is preventative medicine?

The act of improving and maintaining patient well being in order to prevent disease, illness, disability, or untimely death

primary prevention:

 focusing on interventions b4 the onset of disease to reduce risk of developing health problems 

• Ex: vaccination against a disease, health education

secondary prevention:

targeting individuals w existing RFs or early signs of disease to halt or slow progression 

• Ex: W screen for mammograms to secondarily prevent breast CA

what is the recommended screening for prostate cancer?

PSA screening

are digital rectal exams recommended for screening of prostate ca?

NO!

• DRE not recommended as screening test due to lacking evidence of benefits

ages & recs for prostate cancer screening:

• men aged 55-69 should undergo periodic PSA screening

  • ***for 55yo, discuss the risks & benefits of PSA screening & proceed based on the patient’s preferences 

• >70 yo PSA-based screening not recommended

• consider 40-45yo for high risk pts

  • repeat every 1-2yrs -3

what are the ages & screening recs for breast cancer?

Younger than 30:

• US is the preferred initial modality. Incidence of breast cancer is <1% in this group.

30–39: 

• Either is okay but  recommended to do  both as initial

40 years and older:

• Diagnostic mammography is the best initial diagnostic test

  • +/- PRN US

protocol for women aged 50-74 who are at average risk for breast cancer:

recommended mammograms every 2 years

think- 2 boobs, so every 2 yrs

if pt has famhx & noticed a lump, what should u do (breast CA)?

obtain diagnostic digital mammogram

75 or older breast ca screening:

dont necessarily need it; talk w provider

what is BI-RADS 3 & what do u do for it?

probably benign; short-interval (6month) follow up

what is BI-RADS 4&5 & what do u do for it?

4= suspicious

5= highly suggestive

both require biopsy for tissue diagnosis

what is BI-RADS 6 & what do u do for it?

6= biopsy-proven malignancy

requires surgical excision

at what age should u start colorectal cancer screening?

45yo

what ages require colorectal cancer screening?

45-75

Guaiac-based fecal occult blood test (gFOBT):

uses chemical guaiac to detect blood in the stool

• Recommended annually

Fecal immunochemical test (FIT):

uses antibodies to detect blood in the stool; sensitivity not amazing 

• Recommended annually

FIT-DNA test:

also known as stool DNA test(cologuard). Combines the FIT with a test that detects altered DNA in the stool; great sensitivity 

• Recommended once every 3 years

think- DNA=3 letters→ Q3 yrs

 Flexible sigmoidoscopy:

A short, thin, flexible, lighted scope inserted into the rectum to visualize the lower third of the colon; (doesn’t go as proximal as colonoscopy)

• Recommended Q5 years OR Q10 years w FIT every year

think- flexible bc can do Q5 or Q10yrs

when can u get flexible sigmoidoscopy every 10 years?

if you do a FIT test annually

Colonoscopy:

 Longer, thin, flexible lighted scope to visualize the entire colon

• Recommended Q10 years for people at average risk of colorectal cancer

• Most sensitive for lesions 

CT colonography (virtual colonoscopy):

Uses X-rays and computers to produce images of the entire colon which are displayed on a computer screen; good sensitivity for lesions 

• Recommended Q5 years

how often is each test option for colorectal cancer screening?

• Colonoscopy Q10 years

• FIT annually 

• gFOBT annually 

• FIT-DNA Q3 years 

• Flexible sigmoidoscopy Q5 years or Q10 years with FIT Qyr 

• CT colonoscopy Q5 years

which colorectal cancer screening test is LEAST expensive?

FIT ($30-90)

which colorectal cancer test is MOST expensive?

Colonoscopy  ($1500-2500)

which colorectal cancer screenings are prophylactic?

colonoscopy is the only one that is diagnostic & therapeutic

prices of main colorectal cancer screening techniques:

1. Colonoscopy  ($1500-2500)

2. FIT-DNA (cologuard) ($500-600)

3. FIT ($30-90)

4. CTC ($250-1000)

RFs for testicular cancer:

• Undescended testicle

• personal history

• family history

• HIV

• age 20-34

what is the recommended exam for testicular cancer?

if suspicious of testicular mass, do testicular US & labs

should self-exam be done to screen for testicular cancer?

NO

• recommends against screening for testicular cancer in adolescent or adult men thru self-exam or regular clinical exams

RFs for cervical cancer:

HPV, sexual activity, smoking, immunosuppression (AI disease, HIV, transplant), STDs, OCPs, >3 full term pregnancies, young age at first full-term pregnancy, socioeconomic status, DES, family history, genetic mutations

if pts mom has cervical cancer, should pt be worried ab it for themselves?

no, its not hereditary

what cervical cancer screening should be done at ages 21-29?

screening Q3 years w cervical cytology alone

what cervical cancer screenings should be done at ages 30-65?

screening Q3 years w cervical cytology alone, Q5 years w high-risk HPV testing alone, or Q5 years w hrHPV testing in combination with cytology

what do the pap smear changes mean?

• Normal-“negative”. Means that no cell changes were found on the cervix.

• Unclear-“ASCUS”. Abnormal cervical cells. Unclear if related to HPV. Could be related to pregnancy, menopause or infection.

• Abnormal–Cell changes found on the cervix. Likely caused by HPV. Often resolve on it’s own but able to develop into cancer. Can be low-grade or high-grade.

• Unsatisfactory–There are not enough cells in the sample or they are clumped together and cannot be evaluated

when are pap smears done?

• Pap smears begin at the age of 21 REGARDLESS of sexual activity

  • Then done every 3 years

cervical cancer screening guidelines:

when should clinicians screen for intimate partner violence?

in women of reproductive age

RFs of drug & alc dependence:

Family history, Availability of substance, Parental neglect, Childhood adversity, History of child, physical and/or sexual abuse, History of mood disorder, Depression, PTSD, Impulsivity

what are the screening options for alcohol?

• AUDIT-C

• SASQ

• CAGE

• TWEAK

ASCT→ Alcohol Screening Counseling Tool

what are the screening options for drug use?

• NIDA Quick Screen

• ASSIST

• TAPS

what is TWEAK vs TWEAK (C)?

they are both screening for alcohol, but TWEAK (C) is for pregnant patients

intervention for alcohol use:

• SBIRT approach

• Cognitive behavioral strategies

• Pharmacological options

intervention for drug use:

• SBIRT approach

• Cognitive behavioral strategies with high emphasis on relapse prevention

• Pharmacological options

  • Testing for bloodborne pathogens

RFs of obesity:

• Lack of physical exercise

• Unhealthy eating habits

• Low quality sleep

• Stress

• Health conditions

• Genetics

• Medications

• environment

what measures do u use to screen for obesity?

BMI or waist circumference

who should be offered and/or referred to intensive, multicomponent behavioral interventions?

pts w BMI >30

RFs for unintentional injury:

• Drowning (A leading cause of death for children): inability to swim, missing/ineffective fences, lack of supervision, location, not wearing life jackets, drinking alcohol or using prescription drugs

• Transportation safety: Alcohol, drugs, distracted driving, risky driving, inexperienced driving, nighttime driving, rural vs urban driving

• Older adult falls: medical conditions that affect vision, balance, sensation, postural hypotension, sarcopenia, medications, cluttered environment,

• TBI and concussions: high-risk/collision sports, falls, lack of safety equipment, history of prior TBI

RFs for intentional injury:

• Community: Perpetrators with low IQ, involvement with illicit substances, mental health diagnoses, exposure to violence, gang involvement, poor academic performance

• Firearm: Perpetrators with violent history, violent victimization, drug/alcohol misuse, impaired cognition and poor judgment

• Intimate partner: Victims of young age, low self esteem, low income, belief in strict gender roles, isolation

• Sexual: Perpetrators with aggressive behaviors, early sexual initiation, exposure to sexually explicit media, strict gender roles

ages of abuse:

• children <4yo, children w special needs, illness

• elderly

which screening tools are used for injury & abuse?

• HARK

• HITS

screening for abdominal aortic aneurysms- age & what:

One-time screening with ultrasonography in men aged 65-75 who have ever smoked to R/O aaa

If aaa is <3cm, what should be done?

nothing, no rescreening

if aaa is 3-3.9cm, what should be done?

rescreen with ultrasonography every 2-3 years

if aaa 4-5.4cm, what should be done?

• rescreen with ultrasonography or CT every 6-12 months. 

  • Consider surgical consultation at 5 cm

if aaa >5.4cm, what should be done?

Surgical consultation for elective repair

what are the interventions for aaa?

• Smoking cessation

• Pharmacological

• Surgical intervention

what is the primary prevention of lung cancer?

smoking prevention & cessation

what is the secondary prevention of lung cancer?

low dose CT at age 50-80yo with a 20+ pack year history 

• If havent smoked for 15 or more years, no need for screening