Somatic symptom & related disorders 🧍‍♂️

when does somatic symptom disorder occur (SDD)?

occurs when a person feels extreme, exaggerated anxiety about physical sx

• Intense thoughts, feelings, and behaviors related to sx

• Impairs activities of daily life

they are NOT FAKING the sxs they are really experiencing it, FULLY real pain, it is just an exaggerated threat that the sxs come with

pain is not as extreme as reaction but it is still real pain

what is diagnostic criteria for SDD?

One or more sx that are distressing or result in significant disruption of daily life

• Disproportionate, persistent thoughts about seriousness of sx

• Persistently ↑ anxiety about health or sxs

• Excessive time + energy devoted to these concerns

doest have to be the same sxs

like nose runs = i have CSF leak (6 mo)

then, back hurts = i have metastatic cancer (6 months)

where will somatisizing patients often present?

often use dispropertionately large amount of medical services

constantly come in with severe anxiety about concerns that are ambiguous or strange

rarely seek help from psychiatrists on their own initiative

healthcare workers will eventually realize something psychiatric is going on after multiple ambiguous visits usually

what is the symptomology of SDD?

sxs tend to be fluid (pts describe different disorders at different times)

they are caused or facilitated by numerous interrelated factors and some sxs may have multiple etiologies

what is functional neurological symptom disorder?

complex condition causing neurological symptoms without apparent structural problem in NS

usually from stress

what is diagnostic criteria for functional neurological symptom d/o?

• One or more sx of altered voluntary motor or sensory function

• Symptom or deficit is not better explained by another medical or mental disorder

• Causes clinically significant distress or impairment in social, occupational, or other important area of function

what is the etiology of functional neurological symptom disorder?

often follows traumatic event and may be psychological mechanism to cope with acute stress

what are clinical symptoms of functional neurological symptom disorder?

• Mimics dysfunction in voluntary motor or sensory symptoms

• Pseudoseizures, vocal cord dysfunction, blindness, tunnel vision, deafness, anesthesia, and paralysis

• May be depressed or anxious about sx

they are not pretending to have paralysis in the arm but someone who is not psych with not have deep tendon reflexes

what are most sxs of functional neurological symptom disorder by definition?

pseudoneurologic

what are lab findings of functional neurological symptom disorder?

Nerve conduction speed, EMGs, and visual and auditory evoked potentials demonstrate sensory and NS is intact despite sx

• Simultaneous EMG and video recording of patient with pseudoseizures can be diagnostic → EEG demonstrates normal electrical activity

EEG same time as video and seizure someone with pseudo seizure will ave video seizure but it will not match up with seizure activity on EEG at that time

what is course of illness of functional neurological symptom disorder?

- most sxs remit quickly and spontaneously

- frequently transient reactions to acute psychosocial stressors

- Prolonged symptoms associated with environmental reinforcers

- May occur with recurrence of stressors

what types of differentials must be functional neurological symptom disorder?

possibility of physical disease that pt may have amplified or elaborated

what is malingering? how is it different from functional neurologic symptom disorder?

difference is degree of conscious motivation (higher in malingering)

they are faking it for their own gain i think while functional... are not faking it

how is tx decided for functional neurologic symptoms disorder?

relief may occur spontaneously or with suggestive techniques

if chronic, it is often being reinforced by environmental factors so behavioral techniques are needed

what is psychopharmacology for functional neurologic symptom disorder?

no specific interventions, just treat comorbid conditions like depression

what psychotherapy is used for functional neurologic symptom disorder?

- insight oriented psychotherapy

- behavioral therapy is only choice from chronic

what environmental manipulation can be done as tx of functional neurologic symptom disorder?

pt may present a "cry for help" bc of pressure like underlying physical or sexual abuse that must be stopped

what is prognosis of functional neurologic symptom disorder?

Most remit quickly; those that persist usually have environmental reinforcers

what is illness anxiety disorder?

persistent fear that they have a serious or life-thretaning illness despite few or no symptoms

how will illness anxiety disorder pts present?

somatic symptoms are mild or not present

they avoid going to the doctor from fear of receiving bad news about a diagnosis

If there is a high risk for developing a

medical condition (e.g., strong FHx), preoccupation is clearly excessive or disproportionate

how are the high levels of anxiety in illness anxiety disorder revealed?

excessive health-related behaviors (repeated checks for signs of illness)

maladaptive avoidance (aroids appointments)

lines relates preoccupation present for ≥6 months and specific illness may change over time

what are the clinical sxs.presentation of illness anxiety disorder?

Presents with *fear and

concern about disease* rather than with dramatic symptoms

may come from misinterpretations of normal bodily sensation

what is the course of illness for illness anxiety disorder?

sxs wax and wane and exacerbations may occur at time of occupational or interpersonal stress

what are the differential diagnoses of illness anxiety disorder?

must be re-evaluated continually for possibility that physical disease may underlie each new complaint

what is tx options for illness anxiety disorder?

some pts will accept referral to psychiatrist, but premature referral bay destroy rapport with pcp and make management more difficult

sxs improvement reported with SSRI's

what psychotherapy is used for illness anxiety disorder?

- usually POOR candidates for insight oriented psychotherapy because they are alexithymic (unable to express feelings with words)

- CBT can be used

- group therapy can help

what are possible comorbid conditions with illness anxiety disorder?

- depression, anxiety, OCD

- tend to be very sensitive to meds SE so need very low doses

how should illness anxiety disorder be managed?

each new complain should be accompanied by limited evaluation

and invasive procedures should be avoided without clear indications

what are the complications of illness anxiety disorder?

iatrogenic complications

illness caused by medical treatment or examination

what is prognosis of illness anxiety disorder?

pts will not be cured

but have significant relief when comorbid conditions are treated

what is the main difference between SDD and hypochondriasis?

main difference is there is an actual symptom in SSD but there isn't in hypochondriasis

when is diagnosis of somatic symptom disorder made?

when person has significant focus on physical sxs to a level that results in major distress or functional problems

why are most cases of somatization disorder not diagnosed?

"doctor shopping"

what are the signs/sxs of somatic symptom disorder?

- multiple unexplained sxs, often with urgency

- subject to numerous invasive diagnostic or tx procedures

- multi systemic sxs

what is the course of illness of somatization disorder?

number and intensity of sxs wax and wane over time but frequently persist to late un life

what re the differential diagnoses of somatization disorder?

- difficult to dx physical disease (like SLE)

- may pts get "fashionable diagnoses" like fibromyalgia, chronic fatigue syndrome, total allergy syndrome

- almost always have one or more axis I psychotic diagnoses

what is tx of somatic symptom disorder?

no real tx, van do group experiences that a re supported, instead of insight oriented

how is somatic symptom disorder managed?

Simple management techniques can be used by PCP to ↓ medical

care utilization:

1. Schedule freq. appointments without development of new sx

2. Avoid statements that symptoms are "all in your head"

3. Undertake invasive dx/tx procedures only if objective signs + sx are present

4. Prescribe all medications and coordinate medical care

what are the complications of somatic symptom disorder?

risk for iatrogenic complications

prine to impulisve acting out behaviors so caution when giving potentially lethal meds

what is prognosis of somatic symptom disorder?

• Chronic problem that continues throughout a patient's life

• Management principles aimed at reducing sx and containing costs

• Frequent iatrogenic complications are problematic

what is body dysmorphic disorder?

patients cant stop thinking about one or more perceived defects or flaws in appearance

which causes significant distress, embarrassment, shame, anxiety

what is diagnostic criteria of BDD?

- preoccupation with one or more defects or flaws in appearance that are not observable to others

- repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (comparing appearance to that of others) in response to concerns

what type of disorder is BDD?

obsessive-compulsive and related disorders

what is possible etiology of BDD?

- comorbid

- OC spectrum of disorder and societal anxiety and MDD

what are the s/sxs of BDD?

• Pt may visit physicians multiple times seeking treatment, esp.

surgical intervention to correct defects that are imperceptible to

normal observer

• May spend considerable time in repetitive behaviors to improve or

hide perceived defects

• May include attempts to camouflage defect such as excessive

grooming, picking at skin

• Little insight into condition, with a considerable proportion can be

described as delusional

what is course of illness for BDD?

- usually start in adolescence

- most extreme can be with complete societal withdrawal and high suicide incidence

- freq seek multiple consults from derm or plastic surgeons

what are the differentials for BDD?

• Includes delusional disorder, somatic type and anorexia nervosa

• Majority have comorbid psychiatric disorder, m/c MDD, social phobia, psychotic d/o, OCD, substance use d/o, and personality d/o

• ↑ rates of suicidal ideation and attempts

what should be done when BDD pts request/seek surgery?

psychiatrist asked to render an opinion as to whether surgery is contraindicated

best describes as syndrome of heterogeneous etiology

what is pharm intervention for BDD?

SSRI technically off label but first line

what is psychotherapeutic intervention in BDD?

CBT

emphasizes cognitive restructuring, exposure with response prevention, and behavioral experiments testing dysfunctional thoughts and beliefs

what are complications of BDD?

important to recognize pts psychosis ~ increased suicide ideations

seeking further operations