Winter 2024 Somatic Symptom Disorders.pdf

Somatic Symptom Disorders Dr. Nicole Kostiuk, R. Psych HYSTERIA › › The wandering uterus 19th century › Charcot hypnotizes patients to facilitate the presentation of their symptoms › Freud and Breuer (1905); “Studies on Hysteria” › › › Anna O. The talking cure Conversion derives from psychoanalytic...

Somatic Symptom Disorders Dr. Nicole Kostiuk, R. Psych HYSTERIA › › The wandering uterus 19th century › Charcot hypnotizes patients to facilitate the presentation of their symptoms › Freud and Breuer (1905); “Studies on Hysteria” › › › Anna O. The talking cure Conversion derives from psychoanalytic tradition › Emergence of physical symptoms as an attempt to resolve or communicate unconscious and unbearable psychic conflicts DSM-IV-TR vs. DSM-5 › Previously Somatoform Disorders and Factitious Disorders in DSM-IV-TR › › › › “Somatoform Disorders was confusing” › Still very confusing!! Great deal of overlap Lack of clarity between diagnoses Overemphasized centrality of medically unexplained symptoms › Unfair to diagnose a mental condition because a medical cause cannot be demonstrated › Implies that their physical symptoms are not real DSM-IV-TR vs. DSM-5 › The Somatic Symptom and Related Disorders of the DSM-5 › Significant change in diagnostic criteria for individuals with chronic health-related concerns for which there is limited medical evidence › Research suggested that the numerous specific criteria did not facilitate clinical understanding or treatment for patients presenting with medically unexplained physical symptoms › No longer the suggestion that the symptoms are primarily psychological in origin › Reduced # of diagnoses › › Improve diagnostic clarity Positive symptoms › › Distressing somatic symptoms plus abnormal thoughts and feelings in response to symptoms Medically unexplained symptoms remains in conversion disorder (now Functional Neurological Symptom Disorder) › Possible to demonstrate definitively that symptoms are not consistent with medical pathophysiology Related Diagnoses Subsumed Under Functional Somatic Syndromes › Strongly associated with somatoform disorders Fibromyalgia › Multiple chemical sensitivity › Chronic fatigue › › Note that chronic medical illness/disease and SSD’s are not mutually exclusive but also not synonymous › When seen together, tend to have poorer prognosis Proposed Term › Cogniform Disorder In neuropsychology literature › Describe presentation characterized by pervasive concerns about cognitive problems › Biopsychosocial Approach › Verity of diagnosis not as relevant as the presence of the symptoms Context in which the symptoms present › How entrenched they are › Impact on functioning › › BPS approach suggests that context and history is as important as the illness › Consider the complexity of other factors influencing presentation Risk Factors › Females > Males › Hormonal mechanism? › Males underreport? › › › › › › › › 7 x more likely to be diagnosed with fibromyalgia 4 x more likely to be diagnosed with chronic fatigue syndrome 9 x more likely to be diagnosed with multiple chemical sensitivity 2-3 x more likely to be diagnosed with irritable bowel syndrome 3 x more likely to be diagnosed with psychogenic nonepileptic seizures Trauma Age › Due to psychosocial stressors? Race/Culture › Greater prevalence in minorities and lower socioeconomic status › Perhaps due to cultural acceptance of certain kinds of symptoms and presentations Comorbidity › Typically characterized by high levels of psychiatric symptoms › Particularly depression and anxiety › Often treated with antidepressants Course › Typically show symptoms early in life › › By mid-20’s typically have many symptoms Heavily involved with medical system › Multiple providers and specialists Quest for answers intensifies through young adulthood into middle age › Course of symptoms is variable › › Rarely go for several months without consultation with medical provider or treatment of some kind Historically prognosis is poor › Respond poorly to psychotherapy › Expectations for Neuropsychological Results › Lack of consistent relationship between diagnoses and neuropsychological functioning Increased level of failure on symptom and performance validity measures › Emotion and Personality: limited insight and tendency to externalize blame › › Likely see symptoms as responsible for difficulties Somatic Symptom Disorder (formerly Hypochondriasis) › DSM-5 criteria › 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: › › › 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. Somatic Symptom Disorder › › C. Although any one somatic symptoms may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months) Seek a lot of medical attention › Does not help/unresponsive to medical interventions › Doctor-shopping › Often unusually sensitive to medication sideeffects › Many report medical attention has been inadequate Illness Anxiety Disorder › › › A. Preoccupation with having or acquiring a serious illness B. 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, the preoccupation is clearly excessive or disproportionate C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status Illness Anxiety Disorder D. The individual performs excessive healthrelated behaviours (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctors appointments and hospitals › E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time › Somatic Symptom and Illness Anxiety Disorders › Share many features with anxiety and mood disorders › Particularly panic disorder Often comorbid › Defining characteristic is anxiety › Preoccupied with bodily symptoms, › Misinterprets them as indicative of illness › Essentially is a disorder of cognition with strong emotional contributions › Formerly Hypochondriasis Treatment › Often are not seen by mental health Why? › Little is known about effective treatment › Psychoeducation/reassurance › Reduce stress, increase coping resources › CBT › “Prescribe the symptoms” › › Paradoxical technique Functional Neurological Symptom Disorder (Formerly Conversion Disorder) › https://www.youtube.com/watch?v=_jOu qAcgMrA Functional Neurological Symptom Disorder › FYI: “functional” refers to a symptom without an organic cause › A. One or more symptoms of altered voluntary motor or sensory function › › › › Motor: weakness or paralysis, abnormal movements, such as tremor or dystonic movements, gait abnormalities, and abnormal limb posturing Sensory: altered, reduced, or absent skin sensation, vision, or hearing. Psychogenic or non-epileptic seizures: generalized limb shaking with apparent impaired or loss of consciousness, syncope (fainting), or coma Speech: reduced or absent speech volume, altered articulation, sensation of a lump in the throat Functional Neurological Symptom Disorder › › B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions Not diagnostic, but... › › › Onset often acute following a psychological conflicting situation May deny any emotional problems and be resistant to psychiatric consult Secondary gain? › Suggests factitious or malingering Functional Neurological Symptom Disorder › Converting emotional pain into physical pain › Biological links Serotonin and norepinephrine influence both pain and mood › Shared neurologic pathway › Functional Neurological Symptom Disorder › Assessment: CHALLENGING!!! › Medical Physicians, neurologists › Blood tests, CT scans, MRI scans, EEG, neurology exams, etc all come back normal › › Psychological PAI: Somatic Complaints Scale › Inconsistent neuropsych profiles › MMPI-2 Conversion V › Functional Neurological Symptom Disorder › Treatment › › Avoid invasive diagnostic and therapeutic interventions Tactful presentation of the diagnosis › › Avoid giving the impression that nothing is wrong Assure that symptoms are real despite lack of medical cause › › Psychoeducation › › › › No one thinks they are faking Provide examples of diseases deemed stress-related (e.g., ulcer, hypertension) Provide examples of emotions producing symptoms (e.g., increased heart rate, feeling queasy when anxious) Provide examples of how unconscious can influence behaviour Physiotherapy › Provides ego-syntonic way of getting better Functional Neurological Symptom Disorder › Treatment › Hypnosis: › › › › › › Anecdotal evidence only › Identify distorted cognitions related to illness Psychoanalysis Behaviour Modification CBT Family Therapy Often rejects/criticizes help offered › Resistant to suggestions that difficulties are even partly psychologically based › Pessimistic that anything can help them Factitious Disorders › Two Types: › Factitious Disorder Imposed on Self (Munchausen’s) › A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception › › › › Must demonstrate that the individual is taking actions to misrepresent, simulate, or cause signs of symptoms Methods can include exaggeration, fabrication, simulation, and induction B. The individual presents to others as ill, impaired, or injured C. The deceptive behaviour is evident even in the absence of obvious external rewards › Reward is to assume the sick role and gain attention Factitious Disorder › Factitious Disorder Imposed on Another (Munchausen’s By Proxy) › Same criteria as Factitious Disorder Imposed on Self, but the individual presents another individual (victim) to others as ill, impaired, or injured › Could be children or pets FND vs Factitious Disorders › In clinical practice the distinction between conversion and factitious disorders can only be considered definitive if corroborated by covert surveillance or confession › Essentially need to be able to see/prove that person has caused it to diagnose Factitious Disorder Malingering Not a psychiatric disorder › Exaggerating or faking for personal gain › › › E.g., money, time off work, litigation, etc. Assessment Test of Memory Malingering (TOMM) › Green’s Word Memory Test › MMPI-2 › › Elevated F scales Treatment › Characterized by frustration and ambivalence › › On the clinician’s part!! Pharmacologic Treatment › Symptoms management with medication Pain (opiates) › Depression (SSRI’s and TCA’s) › Anxiety (Anxiolytics) › Malaise (Stimulants) › › Meta-analyses: Little effects › Adverse effects of medications › › Cognitive Behavioural Therapy: › Most research is on CBT › Evidence of superiority to wait list and usual care › › Motivational Interviewing: › › Little research, but frequently used in primary care Mindfulness Based Therapy: › MBSR and ACT › Orient patients to awareness of present moment and nonjudgmental acceptance of experiences › › Small effect size Often combined with CBT, so difficult to determine effectiveness Treatment for co-occurring sleep disorders: › CBT-I › Stimulus control › Sleep restriction › Sleep hygiene › Relaxation training