Somatic Symptoms and Related Disorders PDF

Somatoform Disorders (Symptom and Related Symptoms) Alicia L. Turner, MSN,RN  Introduction Group of illnesses where bodily signs and symptoms are a major focus Believed to originate from faulty mind-body interactions- the brain sends signals that impinge on the patients...

Somatoform Disorders (Symptom and Related Symptoms) Alicia L. Turner, MSN,RN  Introduction Group of illnesses where bodily signs and symptoms are a major focus Believed to originate from faulty mind-body interactions- the brain sends signals that impinge on the patients awareness falsely suggesting a serious problem in the body The symptoms are medically unexplained Patients are convinced that their suffering comes from some type of undetected and untreated bodily derangement  Historical background……. “Somatoform”/ “ Somatic” derived from Greek “soma” – body Grouped together for the first time in the DSM III in 1980 Observed for a long time before that and several terms used to refer to these disorders including neurasthenia, hysteria and Briquet’s syndrome Some famous contributors-Jean Marie Charcot, Paul Briquet, Sigmund Freud  Somatoform disorders 1. Somatization disorders- multiple organ system involvement 2. Conversion disorders- neurological complaints 3. Hypochondriasis- worried about being sick with a particular illness rather than a focus on physical symptoms (Now Illness Anxiety disorder in DSM V) 4. Body dysmorphic disorder- dissatisfaction with a body part (Now shifted to Obsessive disorders in the DSM V) 5. Persistent somatoform pain disorder- pain is the main complaint (Now part of Somatic Symptom disorder in DSM V) 6. Undifferentiated somatoform disorder 7. Somatoform disorder not otherwise specified  DSM V: Somatic Symptoms and related disorders Somatic Symptom Disorder Illness anxiety disorder (Hypochondriasis) Conversion disorder (Functional Neurological Symptom disorder) Psychological Factors affecting other medical conditions Factitious disorders Other specified Somatic Symptoms and related disorders (pseudocyesis) Unspecified Somatic Symptom and related disorder  Somatic Symptom disorder A. One or more somatic symptoms that are distressing or result in significant disruption of daily life B. Excessive thoughts, feelings or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: Disproportionate and persistent thoughts about the seriousness of one’s symptoms Persistently high levels of anxiety about health or symptoms Excessive time and energy devoted to these symptoms or health concerns C. State of being symptomatic is persistent > 6 months Specify: predominant pain, persistent, severity  Somatic symptom disorder A- many physical symptoms - starting before the age of 30 - occur over a period of years - leads to multiple medical consultations and other attempts at seeking treatment -significant impairment in social, occupational, or other areas of functioning B -4 pain symptoms- related to at least 4 different sites or functions -2 gastrointestinal symptoms other than pain -1sexual or reproductive symptom -1 pseudoneurological symptom  Somatic Symptom disorder C- despite appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance -when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what could be expected from the history, physical examination, or laboratory findings. D- the symptoms are not intentionally produced or feigned  Somatic symptom disorder Facts More in women (life time prevalence 0.2-2% of women and 0.2% of men) 5-10 % of patients presenting to a PCP Inversely related to social position Usually beginning in teenage years Often co-morbid with other mental disease such as depression and anxiety Common personality traits-avoidant, paranoid, self- defeating, obsessive- compulsive  Somatic Symptom disorder Psychodynamic factors Learning theory Social/Cultural factors Biological factors Genetic factors Cytokines  Somatization disorder-clinical features Common characteristics of presenting problem Long, complicated medical histories-confused time frames Patients frequently report they have been sickly all their life Psychological and interpersonal problems Suicide threats common but rarely acted upon Dramatic and emotional presentation of history and appearance Self centred, hungry for admiration, manipulative Common Symptoms reported Nausea and vomiting other than during pregnancy Pain in the arms and legs Shortness of breath unrelated to exertion Amnesia Complications of pregnancy and menstruation  Somatic Symptom Disorder-Treatment Plan Single, identified physician as primary care giver Regular, scheduled visits usually at monthly intervals Keep interviews brief with a partial physical exam for each new symptom expressed Generally avoid lab/diagnostic investigations Once diagnosed view these problems as being communications of emotional distress Try and raise awareness of these symptoms being responses to psychological pressures and see if you can motivate patient to see a mental health clinician Individual or group psychotherapy  Somatic Symptom disorder- tasks of psychotherapy Decrease the patients personal health expenditures Help to cope with their symptoms Assist with expressing underlying emotions Help to develop alternative strategies for expressing their feelings Psychopharmacological intervention difficult Conversion Disorder (Function Neurological Symptom Disorder) Neurological complaint With weakness or paralysis With abnormal movement With swallowing problems With speech problems With attacks or seizures With anaesthesia or sensory loss With special sensory symptoms With mixed symptoms  Conversion disorder Qaulifiers: Acute Episode < 6 months Persistent With/out psychological stressor  Conversion Disorder A- one or more symptoms of deficit affecting voluntary motor or sensory function B-Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions C-The symptom or deficit is not better explained by another medical or mental disorder D-The symptom or deficit causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrants medical evaluation  Conversion disorder Common amongst: -F>M -rural population -little education -low social economic status -military personnel exposed to combat situations Co-morbidities include-MDD, Anxiety, schizophrenia, somatisation, histrionic pd, passive-dependent pd  Conversion disorder-clinical features Sensory deficits Motor symptoms Anaesthesia of extremities Involuntary movements Midline anaesthesia Tics Blindness Blepharospasm Torticollis Tunnel vision Opisthotonus Deafness Seizures Abnormal gait Visceral symptoms Falling Psychogenic vomiting Astasia-Abasia Pseudocyesis Paralysis Globus hystericus Weakness Swooning or syncope aphonia Urinary retention diarrhea Conversion disorder-Etiology Psychodynamic factors- intra- psychic conflict, repression, sublimation, projection Learning theory/ social factors – nonverbal means of controlling and managing others Biological factors- impaired hemispheric function Genetic factors- women probands more prone to somatisation, depression and anxiety, male probands more prone to ASPD and substance abuse  Psychological Concepts in Somatoform disorders Primary Gain- distracts from primary intra- psychic conflict Secondary Gain-receives tangible benefits to sick role La Belle indifference-indifference to what should normally be anxiety provoking symptoms Identification-assumption of symptoms of a significant other  Conversion Disorder-Course and Prognosis Usually acute onset Resolves in a few weeks 20% of individuals with diagnosis have relapse in 1 year Good prognostic factors- clearly identifiable stressor, acute onset, above average intelligence and quick institution of treatment  Illness Anxiety disorder Preoccupation with having or acquiring a specific illness Somatic symptoms not present or mild Concern excessive if at high risk or if another medical condition present High level of anxiety about health, easily alarmed about personal health status Performs excessive health related behaviours or exhibits maladaptive avoidance Lasting 6 months or more Preoccupation causes significant impairment or distress in a person’s life  Illness Anxiety Disorder- Etiology Psychodynamic factors- intra-psychic conflict, projection, deserving of punishment Learning theory/ social factors –symptoms often learnt from past experiences, often have related medical illnesses Biological factors- low threshold for and low tolerance of physical discomfort  Illness Anxiety Disorder- Treatment Psychiatric treatment in a medical setting Focus on stress reduction and education in coping with a chronic illness Appear to do well in group therapy because it provides them with the social support and interaction that they need Long term regular follow up with physical exams and investigations as necessary reassures the patients that their physicians are not abandoning them and their complaints are being taken seriously. Pharmacotherapy useful only when hypochondriacs have an underlying drug responsive condition.  Psychological Factors Affecting other Medical Conditions Physical Medical condition is present Psychological or Behavioural factors affect the medical condition: 1. Influence the course of the medical condition- exacerbation or delayed recovery 2. Interfere with treatment of the medical condition 3. Constitute additional well-established health risks for the individual 4. Factors influence underlying pathophysiology, precipitating or exacerbating symptoms necessitating medical attention Qualifiers: Mild- increased medical risk Moderate- aggravates underlying medical condition Severe-results in hospitalisation or ED attendance Extreme- results in life-threatening risk  Factitious Disorder (MUNCHAUSEN SYNDROME) Deliberate symptom fabrication or self-injury without obvious potential reward Patient identifies self deceptively as impaired or ill Single or recurrent episodes EXAGGERATED symptoms See most often in people who are in or familiar with medical professionals-nurses, doctors Simulation and/or induction of a symptom (using medications inappropriately). Most severe form of the factitious disorders-can result in self harm severe enough to require hospitalization. Factitious disorders