Review of Somatic Symptom, Impulse Control, and Neurodevelopmental Disorders

Somatic Symptom and Related Disorders

• Disorders are somatic symptom disorder but can also be called somatization disorders or somatoform disorder, terms used interchangeably.
• Characterized by physical symptoms suggesting a medical disease, but without organic pathology.
• No identifiable illness or disease process explains the symptoms through lab tests or diagnostic procedures.
• Patients often "doctor shop" due to the lack of medical explanation, increasing stress.

Somatic Symptom Disorder

• Patient reports multiple physical symptoms (e.g., fatigue, stomach pain, GERD).
• Extensive medical testing yields negative results.
• Symptoms unexplained medically lead to patient stress and "doctor shopping."
• Symptoms can affect any body part or system, be vague or exaggerated.
• The individual spends excessive time and energy worrying about the symptoms, believing they indicate physical illness.
• May include anxiety and depressive symptoms, treated with SSRIs (Selective Serotonin Reuptake Inhibitors) to target worry and anxiety, while being aware of not prescribing Anxiolytics routinely due to the risk of addiction.

Illness Anxiety Disorder

• Formerly known as hypochondriasis.
• Excessive worry about having a serious illness, even after medical reassurance.
• Few or no physical symptoms are present.
• The primary issue is intense anxiety about potential physical illness.
• Example: worrying a rash might be cancerous despite medical reassurance.
• SSRIs are typically used for treatment.

Conversion Disorder

• Also known as functional neurological symptom disorder.
• Physical symptoms manifest as neurological or sensory issues without medical explanation.
• Symptoms are linked to underlying psychological conflicts, often unrecognized by the patient.
• Motor or sensory symptoms include difficulty speaking or swallowing.
• Symptoms may resolve internal conflicts; for example, arm numbness develops instead of expressing anger.
• La Belle Indifference: a patient exhibits neurological or sensory symptoms naively, showing indifference to them, serving as an unconscious defense mechanism and a maladaptive coping mechanism.

Factitious Disorder

• The person deliberately pretends to be sick, faking psychological or physical symptoms.
• Formerly called Munchausen syndrome, named after Baron von Munchausen who told exaggerated stories.
• The motivation is to gain emotional care and attention.
• A compulsive element exists, making behavior control difficult.
• Individuals are skilled at convincingly presenting symptoms (e.g., drinking hot water to raise temperature).

Factitious Disorder Imposed on Another

• Formerly known as Munchausen syndrome by proxy.
• A person fabricates symptoms in others (children, elderly, pets) to gain attention. The diagnosis is given to the perpetrator, not the victim.
• Example: Dee Dee Blanchard subjected her daughter Gypsy Rose to abuse by feigning illnesses to gain attention and sympathy because she wanted people to believe her child was sick, seeking emotional care and attention.

Malingering

• Exaggerating symptoms for personal gain (e.g., avoiding work, seeking financial compensation or drugs).
• Tangible incentives drive the behavior, such as money, drugs, or evading responsibilities.
• Example: feigning illness to get a sick day for pay or exaggerating a foot injury to get a handicap parking pass.

Reasons behind Somatic Symptom and Related disorders

• Biological factors: genetic predisposition.
• Psychological factors:
  • Psychodynamic theory: symptoms are related to repression of conflict, specifically in conversion disorder.
  • Behavioral theory: manipulative behavior to gain attention, as seen in factitious disorder imposed on another.
  • Cognitive theory: misinterpreting body sensations, leading to alarm, as seen in illness anxiety disorder.
• Environmental factors: trauma.

Treatment

• Believe subjective information about pain and give medication if prescribed.
• Establish helping relationships.
• Avoid placebos due to ethical concerns (veracity).
• Teach effective coping skills through psychotherapy or group therapy.
• Cognitive behavior therapy is useful.
• SSRIs are used for pharmacotherapy.

Neurodevelopmental Disorders

General points:

• Compassion and understanding are key to raising children effectively.
• 75% of young adults with psychiatric disorders are first diagnosed between 11 and 18 years of age.
• 20% of children and adolescents suffer from major mental illness.
• Mental illness disrupts academic, social, and psychological functioning, stressing both the child and family.
• Diagnosing young children is difficult due to limited language, cognitive, and emotional development.

Predisposing Factors for Neurodevelopmental Disorders

Autism Spectrum Disorder

• Genetic predisposition.
• Neurological implications: alterations in brain structures.
  • Enlarged total brain volume and amygdala size in young children, which may decrease over time.
• Prenatal and perinatal influences: advanced parental age, fetal exposure to valproate, gestational diabetes or bleeding, low birth weight, obstetrical complications.

Attention Deficit Hyperactivity Disorder (ADHD)

• Genetics.
• Biochemical: neurotransmitter imbalances (norepinephrine, dopamine, serotonin).
• Anatomical influences: decreased volume and activity in the prefrontal cortex.
• Prenatal, perinatal, and postnatal factors: prenatal tobacco exposure, premature birth, low birth weight.
• Environmental influences: exposure to elevated lead levels.
• Psychological influence: disruptions in family equilibrium.

Autism Spectrum Disorder

• Estimated 1 in 59 children in the US are identified with autism spectrum disorder. More common in boys than girls.
• Symptoms appear when the infant fails to be interested in others.
• Improved early testing leading to higher rates of diagnosis.
• Severity ranges from mild to moderate to severe.
• Puberty is a turning point; improvements or deteriorations may occur.

Symptoms

• Persistent deficits in social communication and interaction across contexts:
  • Social-emotional reciprocity: Difficulty in back-and-forth conversations, reduced sharing of interests, emotions, and affect.
  • Nonverbal communicative behavior: Abnormalities in eye contact, body language, difficulty understanding or using gestures.
  • Developing and understanding relationships: Difficulty adjusting behavior in social situations, making friends, or showing interest in peers.
• Speech examples:
  • Stilted speech: Overly formal, unnatural language (e.g., "Greetings, my esteemed colleagues, how do you fare this morning?").
  • Scripted speech: Memorized lines from media (e.g., responding to "How is your day?" with "To infinity and beyond!").

Treatment

• Medications:
  • Opioid antagonists (e.g., Naltrexone) for repetitive self-injurious behavior.
  • Second-generation antipsychotics.
• Psychological Treatments:
  • Applied Behavior Analysis (ABA): Encouraging positive behaviors and discouraging negative ones.
  • Early Intensive Behavioral Intervention (EIBI): Long-term therapy to improve language and cognitive skills (40 hours a week).
  • Early Start Denver Model: One-to-one interactions focusing on joint play and activity routines with an adult.
  • Social Skills Training: Improving the ability to navigate social situations, often in a group setting.
• Nursing Interventions:
  • One-to-one interaction to facilitate trust.
  • Determine self-mutilative behaviors: identify triggers and use diversion techniques or replacement activities.
  • Protect the child to prevent self-harming.
  • Provide positive feedback for acceptable behaviors (e.g., eye contact) to facilitate relationships.

Attention Deficit Hyperactivity Disorder (ADHD)

• Diagnosed as predominantly inattentive presentation, hyperactive-impulsive presentation, or combined.
• Symptoms must be displayed for six months to be diagnosed.
• Children and adolescents (16 and under) must exhibit at least six symptoms; those 17 or older must exhibit five.
• Early diagnosis can occur around 5 or 6 years of age, by ruling out ADHD symptomology, to prevent misdiagnosis with conditions such us schizophrenia.

Pharmacology

• Stimulants (increase norepinephrine, dopamine, and serotonin in the central nervous system).
  • Side effects: insomnia and restlessness (administer in the morning, at least six hours before bedtime), anorexia (administer medication immediately after meals).
  • Monitor weight weekly using the same clothing, in the morning.
  • Drug holidays are used to determine medication effectiveness and are strategically implemented to maximize focus on school while minimizing dependancy.
  • Note: Abrupt discontinuation can lead to withdrawal symptoms such as Nausea, vomiting, abdominal cramping, headaches, fatigue.
• Non-Stimulants (e.g., Buprenorphine).
  • The Buprenorphine class cannot be withdrawn abruptly due to risk of hypertensive crisis.

Treatment

• Modify the environment to minimize hazards.
• Modify behaviors using aversive reinforcement.

Disruptive, Impulse-Control, and Conduct Disorders

• All of them are impulsive disorders.

Oppositional Defiant Disorder (ODD)

• Recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures.
• The child is usually negative, defiant, and oppositional.
• Examples of defiant behaviors include:
  • When the parent says, "Can you please complete your homework?", the child replies, "You can't make me do it. I don't care about school."
  • When the parent says, "Don't forget to wash the dishes,"