Somatic Symptoms Disorders

What is somatic symptom disorder described as?

• A history of physical complaints starting before age 30 (pain - most common, GI distress, sexual dysfunction, neurologically oriented symptoms)

• May have positive clinical findings (not enough to fully explain the symptoms)

What is needed for clinical diagnosis for somatic symptom disorder?

• Different pain sites or painful functions

• GI symptoms other than pain (bloating, nausea, ect…)

• Sexual dysfunction other than pain

• Maladaptive thoughts, feelings, or behaviors

What are 2 types of functional somatic syndromes?

• Chronic fatigue syndrome

• Fibromyalgia

Are CFS and FM in the DSM V?

No

What type of diagnosis is FM and CFS classified as?

Medical diagnoses with psychological components

What are the core symptoms of CFS?

• Chronic fatigue for over 6 months

• No alleviated by rest

• Abnormal fear of physical exertion (kinesiophobia)

• 4 of the following in addition:

  • Impaired memory or concentration, sore throat, tender cervical or axillary lymph nodes, muscle pain, multijoint pain, new headaches, unrefreshing sleep, post exertion malaise

What is the etiology of CFS?

Unknown

What are precipitating factors associated with CFS?

Stress events, infectious disease

What the age onset of CFS?

29-34 years old

What percentage of cases are made up by women for CFS?

75%

What are the treatments associated with CFS?

• Cognitive Behavioral Therapy

• Medications

• Diet

• Exercise parameters individualized but MODERATE and graded - focus on enjoyable activities

What medication is used for CFS?

• Pain relievers

• Antidepressants

What is the purpose of cognitive behavioral therapy for CFS?

• Locus of control over symptoms

• Gradual progress and monitoring of physical activity

• Sleep behaviors

What are the core symptoms for Fibromyalgia (FMS)?

Central sensitization of the CNS that produces increased nociceptive pain responses to a variety of sensory stimuli, this results in generalized muscle aches with specific tender points, stiffness, fatigue, and often poor sleep hygiene

What are the proposed etiology of FMS?

Basic susceptibility (genetic), early childhood experiences, related viral illness, environmental stressors

What does FMS have a high incidence of co-morbidity?

CFS, depression, anxiety

What is Fibromyalgia Tender Points replaced with?

• Widespread Pain Index (WPI)

• Symptom Severity Scale (SS)

What are all the criteria that need to be met for Fibromyalgia Tender points?

1. Generalized pain in at least 4/5 regions

2. Symptoms present for more than 3 months

3. Diagnosis of exclusion

4. WPI of 7 or more and SS of 5 or more OR WPI 4-6 and SS of 9 or over

What are the treatments for Fibromyalgia?

• Cognitive Behavioral Therapy

• Myofascial release, joint manips, TENS, trigger point injections may help reduce nociceptive barrage

• Medications

• Focus on progress intensive aerobic exercise, activity self0management, relaxation techniques, and education

• Exercise management well documented in literature, less controversial than with CFS, despite both disorders tendencies to produce increased symptoms with increases in physical activity

What is illness anxiety disorder?

• Individuals with high health anxiety

• Without somatic symptoms

What are characteristics of conversion disorder?

• Symptom occur without physical explanation, may be result of psychological trauma or stress

• Symptoms are not intentionally produced or feigned and cause significant functional impairment

• Common in adolescents and adults, rare in young children

• Clear association with precipitating psychosocial factor - conflict or stressor precedes the initiation or exacerbation of symptoms

• Relevant psychological factors may not be readily apparent

What are the 4 categories of symptoms presentation of neurological origin for conversion disorder?

• Motor symptoms or deficit

• Sensory symptoms or deficit

• Seizures (with motor and/or sensory symptoms)

• Mixed presentation

What is the treatment for Conversion Disorder?

• Cognitive Behavioral Therapy

• Medications (SSRI’s, anxiolytics, antipsychotics)

• Exposure to social settings or group/family therapy

• Physical therapy may be referred on initial presentation of symptoms

For PT examination, what do you do when the diagnosis is unknown?

Always refer to physician if neurologic symptoms present

For PT examination, what do you do when the diagnosis is known?

Perform evaluation and examination based on report of symptoms

What is Hoover’s Sign?

Test opposite motions simultaneously (hip flexion on left, hip extension on right)

What are the treatment implications for somatic disorders?

• How do you talk to the patient about this diagnosis?

• Not-so-helpful terminology (medically unexplained, nonorganic cause)

• Computer analogy (software problem, not a hardware problem)

• Treat the deficits presented

• Do not challenge the validity of deficits

T/F: Activity makes symptoms worse, but no you are not causing damage.

True

What is factitious disorders?

The intentional production or feigning of physical or psychological symptoms which can be attributed to a need to assume the sick role

What are the types of factitious disorder?

• Factitious Disorder Imposed on Self (Munchausen Syndrome)

• Factitious Disorder Imposed on Others (Munchausen by proxy)

What is Factitious Disorder Imposed on Self?

• Intentional production of physical symptoms to self

• Symptoms produced consciously but reasons may be unconscious or subconscious

• No specific or targeted external gain is identified by individual (money or legal gain)

  • Taking laxatives to induce chronic diarrhea

  • Ingesting chemical substances

  • Purposeful hypoxia

What is factitious disorder imposed on other?

• Intentional production of physical symptoms to another person to fulfill “sick” role by proxy

• Uses hospitalizations, medical procedures to gain praise for caregiver role, very compliant and overly friendly / concerned with patient

• Most often seen in parent/child situations but can occur in any dependent relationship

• Is considered child abuse and must be reported if suspected (feeding child toxic substances and contaminating urine or stool sample)

What are the treatments for factitious disorders?

• Psychotherapy

• Family therapy

• Medication indicated only with comorbid condition like depression or anxiety

Is Malingering a DSM V diagnosis or a factitious disorder?

No

What is Malingering?

• Criminal Behavior, not a Psychiatric Disorder

• Intentional production or feigning physical symptoms

• Symptoms produced consciously WITH conscious specific or targeted external gain is identified by individual (i.e. money, legal gain)

  • Feigning neck pain after accident to avoid work, or to sue the involved individual for large sum of money

  • Intentional production of exacerbating conditions to continue to receive additional workman’s comp payment