Term
| What is a Somatoform Disorder? |
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Definition
• Bodilysymptomsthatsuggestaphysicaldefect or dysfunction
• BUT no physiological basis can be found
• Interferes with functioning, can become part of the core identity
• Accompanied by significant psychological distress
• Somatoform disorders represent the severe end of a continuum of somatic symptoms
• Differentfrom
• Malingering
• Factitious Disorder |
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Term
| Caveat: Adults vs. Children for somatoform disorders |
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Definition
• Physicalsymptomsorcomplaintsofunknown etiology are fairly common in pediatric populations.
• Ex. Many otherwise healthy young children may express emotional distress in terms of physical discomfort, such as stomachaches or headaches, but these complaints are usually transient and do not effect the child's overall functioning.
• Must always consider anxiety and depression, social stressors, abuse->but that’s another lecture |
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Term
| DSM IV->DSM V Changes for somatoform |
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Definition
1. Confusing overlapping categories
2. Terminology experienced as pejorative by both treaters and patients à stigmatizing, contributing to both under and over treatment
3. Unclear threshold for diagnosis
1. DSM V defines symptoms “positively” with core features |
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Term
| Epidemiology of Somatic Symptom Disorder |
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Definition
• General Population: 4%; PC Population: 17%
• Higher utilization patterns (outpatient visits, ER visits, diagnostic tests, medications)
• Poorer response to reassurance
• “Catastrophizing” Cognitive Style |
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Term
| Risk Factors (1) for somatic symptom disorder |
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Definition
• Female
• Fewer years of education
• Lower socioeconomic status or other social stressors
• Concurrent general medical disorders (especially in older patients)
• Concurrent psychiatric disorder (especially depressive or anxiety disorders)
• History of childhood chronic illness
• Family history of chronic illness
• Early childhood experiences of illness and perceptions of significant illness in others are associated with the
experience of medically unexplained symptoms in adulthood
• Parents who fear disease, who are preoccupied with their bodies, and who overreact to minor ailments experienced by their children are more likely to have children with the same tendencies
• History of sexual abuse or other childhood and adult trauma including neglect have been associated with increased physician visits during adulthood |
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Term
| Psychodynamic Origins of somatic symptom disorder |
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Definition
• Historically, both somatoform and dissociative disorders used to be categorized as hysterical neurosis
• In psychoanalytic theory neurotic disorders resulted from the “splitting off” from consciousness unacceptable or
difficult impulses, feelings and memories. This tension created “unconscious conflicts” and anxiety which would then manifest in a more concrete somatic way. |
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Term
| New Theories of Illness for somatic symptom disorder |
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Definition
• “Sickness behavior” (alterations in pain sensitivity including hyperalgesia, sleep disturbance, and fatigue) may be due to activation of inflammatory biology dynamics
• Neural correlates: (eg, prefrontal, supplemental motor, insular, and anterior cingulate cortex) in response to both painful and non-painful stimuli
• Changed Perfusion patterns in the brain |
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Term
| Behavioral and Molecular Genetics and somatic symptom disorder |
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Definition
• Genetic factors are now being considered within the context of psychological models of various somatoform disorders
• The role of specific genetic markers in the development of somatoform symptoms remains unclear
• Somatic symptom concordance rates between monozygotic twins are higher than between dizygotic twins, even when controlling for co-occurring psychiatric symptoms |
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Term
| Neuroanatomy and Neurobiology and somatic symptom disorder |
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Definition
• The hypothalamic-pituitary-adrenal (HPA) axis has been a focus of research in this area
• HPA axis controls glandular and hormonal responses to stress; this may lead to hypocortisolism, which induces
greater stress and enhances experiences of pain and fatigue |
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Term
| Somatic Symptom Disorder (DSM V) |
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Definition
A One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B Excessive thoughts, feelings or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptoms may not be continuously present, the state of being symptomatic is persistent (typically > 6 months). |
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Term
| Diagnosis, Management, Treatment of somatic symptom disorder |
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Definition
• Planned, Scheduled, Fixed-time appointments
• Sufficient workups to satisfy the appropriate level of investigation
• Consider Supervision with Colleagues/Referrals to Psychiatry for help in addressing coping skills, anxiety
• Reduce “rewards”/Remove “reinforcers” of the behavior/symptom (secondary gain)
• Frequent hospital visits, missed time from work/school
• Help Educate Patient that Symptoms may be worsened by comorbid anxiety/stress/depression
• Reassure them that medical tests do not find a cause but this does not mean you “don’t believe them” or “they’re crazy” or “making things up.” |
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Term
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Definition
• Always ask yourself: are you sure about your
“nondiagnosis:”
• Ex. 22 year old F, law student, history of treatment for anxiety presents with loss of vision during exam periodàadvised she was somatizing on multiple ER visits.
She ended up being diagnosed with multiple sclerosis. She had optic neuritis.
But because there was, what I call diagnostic closure, people make up their minds pretty early and don't think about the full list of potential diagnoses, this diagnosis was missed. Now fortunately, it was early enough in the course of the disease that there was no significant change in outcome. And she was able to be well-treated with steroids. But it was a really good example, I thought, of people making up their minds too quickly. |
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Term
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Definition
• Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
• The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
• The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
• The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia. |
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Term
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Definition
• Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
• The preoccupation persists despite appropriate medical evaluation and reassurance.
• The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The duration of the disturbance is at least 6 months.
• The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder. |
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Term
| Illness Anxiety Disorder (DSM V) |
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Definition
• Preoccupation with having or acquiring a serious illness.
• Somatic symptoms are not present, or if present, are only mild in intensity. If another medical condition is present, or there is a high risk for developing a medical condition (ex strong family history), the preoccupation is clearly excessive or disproportionate).
• There is a high level of anxiety about health and the individual is easily alarmed about personal health status.
• The individual performs excessive health-related behaviors (eg. Checks body for signs of illness) or exhibits maladaptive avoidance.
• > 6 months (illness may change)
• Not Explained better by another Mental Disorder
• Specify whether:
• Care-seeking type
• Care-avoidant type |
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Term
| Conversion Disorder (DSM V) |
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Definition
• One or more symptoms of altered voluntary motor or sensory function.
• Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
• The symptom or deficit is not better explained by another medical or mental disorder.
• The symptom or deficit causes clinically significant distress or impairment in social, occupational or other important areas of functioning
• Minimally changed from DSM-IV TR
• Requires clear evidence of incompatibility with neurological
disease
• Reduced emphasis on psychological basis of symptoms
• Specify symptom type:
• Weakness, paralysis, sensory loss, tremor, seizures, etc |
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Term
| Factitious Disorder (DSM V) |
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Definition
• Falsification of physical or psychological signs or symptoms, or induction of injury or disease associated with identified deception.
• The individual presents himself or herself to others as ill, impaired or injured.
• The deceptive behavior is evident even in the absence of obvious external rewards.
• The behavior is not better explained by another mental disorder ex. Delusional disorder or another psychotic disorder.
• Moved into Somatic Symptom and Related Disorders from its own chapter
• NomotivationincludedinDSM-5criteria Divided into:
• ImposedonSelf
• Imposed on another(previously by proxy) |
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Term
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Definition
• B: Background - What is going on in your life? And What brings you in here today?
• A: Affect – How do you feel about that?
• T: Trouble – What bothers you the most about this
situation?
• H: Handling - How are you handling that?
• E: Empathy – That must be very difficult for you.
(factitious) |
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Term
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Definition
1. Stress recently (last week) (yes/no)
2. Symptom count (checklist of 15 somatic symptoms; scored as positive if more than 5 symptoms)
3. Self-rated overall health poor or fair on a 5-point-scale (excellent, very good, good, fair, poor); scored as positive for fair or poor responses.)
4. Self-rated severity of symptoms from 0 (none at all) to 10 (unbearable) scale, scored as positive for responses greater than 5
(factitious) |
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Term
| Take Home Messages for factitious disorder |
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Definition
• Don’t Engage in Diagnostic Closure: • Listen for New Symptoms
• Get Collateral
• Avoid iatrogenic harm
• Treat medical illness fully
• Seek Input/Collaboration from other specialists including psychiatry
Potential Screening Tools:
• PHQ 15
• SSS 8
• Tools for SMI: PHQ 9, GAD 8
Therapeutic modalities such as CBT, biofeedback may decrease anxiety and distress burden
Try to maintain rapport with the patient and co-treaters |
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