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Flashcards in Somatoform Disorders Deck (35)
1

Define MUPS:

Medically unexplained physical symptoms (MUPS)

  • Physical symptoms that prompt the suffer to seek health care but remain unexplained after an appropriate evaluation

2

What are the consequences of MUPS?

  • Impaired physician-patient relationship
    • Physician frustration
    • Patient dissatisfaction
  • Psychosocial distress
  • Decreased quality of life
  • Increased rates of depression and anxiety
  • Increased health care utilization

3

List the types of somatoform disorders:

  • Somatization Disorder
    • [Somatic Symptom Disorder]
  • Conversion Disorder
    • [Functional Neurologic Symptom Disorder]
  • Pain Disorder
    • [eliminated in DSM-V]
  • Hypochondriasis
    • [Illness Anxiety Disorder]
  • Body Dysmorphic Disorder
    • [now classified as an OCD related disorder]

4

What are some generalities of somatoform disorders?

  • Presence of physical symptoms that suggest a general medical condition, but are not explained by a medical condition
  • Psychosocial stress = somatic distress
  • Misinterpretation of normal physiological functions
  • Not consciously produced or feigned
  • Alexithymia

5

Somatization Disorder: 

DSM-IV Criteria

  • Multiple recurring physical complaints that begin before age 30
  • All 4 of the following criteria at some point:
    • 4 pain symptoms
    • 2 non-pain GI symptoms
    • 1 sexual complaint
    • 1 pseudoneurological complaint
  • Not caused by known medical condition
  • Not intentionally produced

6

[Somatic Symptom Disorder]:

[DSM-V Criteria]

  • 1+ somatic symptom that are distressing or result in significant disruption of daily life
  • Excessive thoughts, feeling, or behaviors related to the somatic symptoms or associated health concerns as manifested by:
    • Disproportionate and persistent thoughts about seriousness of symptoms
    • Persistently high level of anxiety about health
    • Excessive time and energy devoted to these symptoms
  • State of being symptomatic is persistent (typically greater than 6 months)

7

Somatization Disorder:

Epidemiology

  • Somatization disorder
    • General population: 0.01%
    • Primary care setting: 3%
  • Subsyndromal somatization disorder
    • General population: 11%
    • Primary care setting: 20%
  • Patients typically found in general medical setting 
  • RARELY seek psychiatric care
    • Often refuse psychiatric care due to belief that symptoms are related to undiagnosed primary medical condition

8

Somatization Disorder:

Clinical Features

  • Patients describe themselves as “sickly”
    • Medical histories are circumstantial, vague, inconsistent and disorganized
    • Describe complaints in dramatic, exaggerated fashion
  • Large number of outpatient visits
  • Frequent hospitalizations
  • Repetitive subspecialty referrals
  • Large number of diagnoses
  • Multiple medications

9

Somatization Disorder:

Differential Diagnosis

  • Primary Medical Disorders!
    • Disorders with transient nonspecific symptoms
      • Examples: MS, MG, SLE, AIDS, AIP, endocrine disorders
  • Psychiatric conditions:
    • Other somatoform disorders
    • Depression
    • Anxiety

10

The 3 features that most suggest a diagnosis of somatization disorder instead of another medical disorder are…

  1. Involvement of multiple organ systems
  2. Early onset and chronic course without development of physical signs or structural abnormalities
  3. Absence of laboratory abnormalities that are characteristic of the suggested medical condition

11

Somatization Disorder: 

Treatment Issues

  • Schedule regular follow-up visits
  • Perform a brief physical exam focused on the area of discomfort on each visit
  • Look closely for objective signs of disease rather than taking the patient’s symptoms at “face value”
  • Avoid unnecessary tests, invasive treatments, referrals and hospitalizations.
  • Avoid insulting explanations such as “the symptoms are all in your head”
    • Explain that stress can cause physical symptoms
  • Set limits on contacts outside of scheduled visits

12

How can psychotherapy be used to treat somatization disorder?

  • Not responsive to long-term insight oriented psychotherapy
  • Short-term dynamic therapy has shown some efficacy
  • Cognitive-behavioral therapy has been shown to be effective

13

How is psychopharmacology used to treat somatization disorder?

  • Antidepressants have shown inconsistent results
  • Antidepressants have limitations in treating somatization disorder
    • Partial response instead of remission
    • Higher discontinuation rates
      • Sensitive to side effects
      • Attribution to physical, whereas antidepressants suggest psychiatric
  • Unknown long-term efficacy

14

Conversion Disorder  [Functional Neurological Symptom Disorder] 

  • Definition: 
  • Clinical Findings: 
  • Epidemiology:

  • 1 + symptom affecting voluntary motor or sensory symptoms, suggesting neurological disorder, proceeded by acute, identifiable stressor
    • [no longer needs to be proceeded by acute stressor]
  • Clinical findings incompatible with symptom presentation and recognized medical or neurologic illness
  • 1/3 patients have true neurological illness
  • 25% recur within the first year

15

What are the clinical features of conversion disorder?

  • “la belle indifference”
  • Symptoms likely to occur following stress
  • Symptoms tend to conform to patients understanding of neurology
  • Inconsistent physical exam

16

Conversion Disorder: 

Treatment

  • Conservative treatment
    • Reassurance
    • Physical and occupation therapy
  • Psychotherapies
  • Amytal interview, hypnosis
    • If the symptom can be resolved by these modalities, they are probably the result of a conversion disorder

17

What are the prognostic factors for conversion disorder?

  • Good prognosis:
    • Onset following a clear stressor
    • Prompt treatment
    • Symptoms or paralysis, aphonia and blindness
  • Poor prognosis:
    • Delayed treatment
    • Symptoms of seizures or tremor

18

Pain Disorder: 

DSM-IV Criteria

  • Pain in 1+ anatomical sites is the predominant focus of clinical attention of is of significant severity to warrant clinical attention
  • Complaints of pain are significantly affected by psychological factors
  • Psychological factors are required in the…
    • Genesis of the pain
    • Severity of the pain
    • Maintenance of the pain
  • Pain is not intentionally produced or feigned

19

Hypochondriasis [Illness Anxiety Disorder]:

DSM-IV [V] Criteria

  • Preoccupation with fears of having a serious illness that does not respond to reassurance after appropriate medical work-up.
  • Belief not of delusional intensity and is not restricted to concern about appearance
  • Duration of at least 6 months
  • [Somatic symptoms typically not present; if present, only mild in intensity]
  • [High level of anxiety about health and easily alarmed about personal health status]

20

Hypochondriasis:

Clinical Features

  • Bodily preoccupation
  • Disease phobia
  • Disease conviction
  • Onset in early adulthood
  • Chronic with waxing and waning of symptoms

21

Hypochondriasis:

Treatment

  • General aspects
    • Establishment of trust
    • History taking
    • Identification of stressors
    • Education
  • Cognitive-behavioral therapy
  • Supportive therapy
  • Pharmacotherapy
    • Serotonergic meds appear to most beneficial

22

Body Dysmorphic Disorder [OCD anxiety disorder]: 

DSM-IV [V] Criteria

  • Pervasive feeling of ugliness of some aspect of their appearance despite a normal or nearly normal appearance
  • If slight physical anomaly is present, person’s concern is markedly excessive
  • [Repetitive behaviors or mental acts in response to appearance concerns]
  • Epidemiology; unknown in general population
    • Dermatologic setting: 12%
    • Cosmetic surgery setting: 6-15%

23

Body Dysmorphic Disorder:

Clinical Features

  • Onset between 15 and 30 years old
  • Appearance preoccupation
    • Any body part
    • Most often involve the face or head
    • Typically think about flaws 3-8 hours/day
  • Compulsive behaviors
    • Intent to examine, improve, seek reassurance or hide perceived defect

24

What are the comorbidities for body dysmorphic disorder?

  • Major depression: 60-80%
  • Personality disorders: 57-100%
    • Avoidant PD is most common
  • Social phobia: 38%
  • Substance use: 36%
  • Obsessive compulsive disorder: 30%

25

Body Dysmorphic Disorder: 

Treatment

  • Avoid iatrogenic harm!
  • Cognitive-behavioral therapy
  • Pharmacotherapy
    • Serotonin-specific medications
      • May reduce symptoms in ~50% patients
    • High-dose and delayed response (10-12 weeks)
  • “Corrective” surgery does NOT work
    • Potential cause of litigation

26

  • How do deception syndromes differ from somtaform disorders?
  • What are methods of inducing illness?
  • What are the deception syndromes?

  • Differ from somatoform disorders in that signs and symptoms are INTENTIONALLY PRODUCED
  • Methods of inducing illness
    • Exaggerations
    • Lies
    • Tampering with tests to produce positive results
    • Manipulations that cause actual physical harm
  • Syndromes
    • Factious disorder
    • Malingering

27

Factitious Disorder: 

DSM-IV Criteria

  • Intentionally exaggerates or induces signs and symptoms of illness
  • Motivation is to assume the sick role
  • External incentives for the illness inducing behavior are absent

28

Describe the epidemiology of factitious disorder:

  • Prevalence in general population is unknown
  • Diagnosed in about 1% of patients seen in psychiatric consultation in general hospitals
  • Likely higher in referral centers

29

What is the etiology of factitios disorder?

  • Little data is available since these patient resist psychiatric intervention 
  • Many patients suffered childhood abuse resulting in frequent hospitalizations
    • Hospitals viewed as safe
  • Self-enhancement model
    • Factitious disorder may be a means of increasing or protecting self-esteem

30

What are the 3 different types of factitious disorders?

  1. Munchausen syndrome
    • 10% of factitious disorder patients
    • Severe and chronic factitious disorder
    • Pseudologia fantastica
  2. Factitious disorder by proxy
    • A person intentionally produces physical signs or symptoms in another person under the first person’s care
  3. Ganser’s syndrome
    • Characterized by the use of approximate answers

31

What is the differential diagnosis for factitious disorders?

  • Must establish the intentional and conscious production of symptoms
    • Direct evidence
    • Excluding other causes
  • True physical illness
  • Other somatoform disorders
  • Malingering

32

What are the predisposing factors for factitious disorders?

  • True physical disorders in childhood leading to extensive medical treatment
  • Employment (present or past) as a medical paraprofessional
  • Severe personality disorder
    • Borderline personality disorder is the most prevalent

33

How is factitious disorder managed?

  • No specific treatment shown effective
  • Early identification
  • Prevent iatrogenesis
  • Beware of negative countertransference
  • Be mindful of legal and ethical issues
  • Address any psychiatric diagnosis underlying the factitious disorder diagnosis
    • Rarely allowed by the patient

34

Define malingering:

  • The intentional production of feigning illness
  • Motivated by external incentives:
    • drugs, litigation, financial compensation, avoidance of work/military, evade criminal prosecution

35

When should malingering be strongly considered?

Consider strongly if:

  1. Medicolegal presentation
  2. Marked discrepancy between person’s claimed stress/disability and objective findings
  3. Lack of cooperation with evaluation and treatment
  4. Antisocial personality disorder