This document provides an overview of several somatic symptom and factitious disorders as defined in the DSM-5 including Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, Factitious Disorder, and Psychological Factors Affecting Other Medical Conditions. It discusses the diagnostic criteria, epidemiology, etiology, clinical features, differential diagnosis, treatment and prognosis of each disorder. The document is intended to educate medical professionals about these conditions.
Sarah, a 34-year-old teacher, has experienced chronic, remitting episodes of depression for 10 years. Her current episode involves low self-esteem, sleep problems, lack of enjoyment, suicidal thoughts, weight gain, despair, isolation, worthlessness and concentration difficulties. Previous treatments with SSRIs provided initial relief but symptoms returned. Amitriptyline was prescribed but exacerbated manic symptoms, leading to a diagnosis of bipolar disorder. Hospitalization and lithium stabilized her condition. The case highlights how bipolar disorder can initially present as depression and the importance of a thorough psychiatric history for correct diagnosis.
A 22-year-old female medical student presented with a two month history of deteriorating concentration, poor memory, and failing tests. Her mother reported disturbed behavior for a year. On examination, she displayed restless and confused behavior with an organized delusional system involving reference, persecution, and sexual delusions. A provisional diagnosis of acute psychotic episode was made, with differential diagnoses of affective disorder or schizophrenia. She was started on antipsychotics, antidepressants, iron supplements, and engaged in supportive therapy, daily activity planning, and family therapy to address biological, psychological, and social aspects of her condition.
1. Said Mohammad, an 18-year-old male from Peshawar, presented with suspiciousness, aggression, insomnia, lack of appetite, and social withdrawal over the past month.
2. His symptoms began one month ago when he started socially withdrawing and expressing beliefs that his family was plotting to kill him. Over the past three days, he became aggressive, refused to eat or sleep, and believed his family would poison him.
3. He was brought to the hospital by his family after attempts to treat him with spiritual healers were unsuccessful. His symptoms appeared to develop after recently relocating with his family due to security concerns.
The patient is a 45-year-old married female who has been experiencing psychiatric symptoms for 12 years. She initially presented with fear, talking to herself, and suspicious behavior. Medications provided minimal relief and her condition has worsened over time. She now experiences auditory hallucinations, delusions that she is being harassed, and shows unpredictable and aggressive behavior. A mental status examination revealed impaired thought processes and insight.
Somatization disorders involve physical symptoms that cannot be explained medically, and are thought to be related to psychological factors. They include somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder. The symptoms are real but are caused or exacerbated by stress and psychological issues rather than physical pathology. Treatment involves psychotherapy and helping the patient manage stress and recognize psychological contributors to their symptoms.
This document discusses several somatic symptom and dissociative disorders including somatic symptom disorder, illness anxiety disorder, conversion disorder, and their diagnostic criteria and features. Somatic symptom disorder involves physical symptoms that cause significant distress or impairment, along with excessive thoughts about the symptoms. Illness anxiety disorder involves severe health anxiety without corresponding physical symptoms. Conversion disorder was historically called hysteria and involves neurological symptoms like paralysis that cannot be explained physically.
Will talk about the severe psychological disorders-- The familiar name for all might be -"Schizophrenia" - it is not just one category but has multiple categories combined under -"Schizophrenia spectrum"
My forensic psychiatric research done in Indian jails shows most convicts under murder cases belong to schizophrenia spectrum (98% schizophrenia and 2% paranoid & schizoid personality disorders), and most have murdered their spouses, family members, friends or colleagues and surrendered themselves on the spot.
This presentation on the "Schizophrenia spectrum" has been particularly shared with you all to extend my message to help these affected people at the right time and maintaining their condition to prevent them from committing such crimes as there is no proper mental health care--Clinical, Legal or authoritative help available for convicts suffering from mental disorder.
The document describes several case studies of patients presenting with various psychological symptoms:
1) M.Zubair, a 26-year-old shopkeeper, presented with intense jerky movements related to anxiety about his upcoming marriage. He was diagnosed with conversion disorder.
2) Parveen Begum, a 35-year-old mother of 4, presented with episodes of loss of vision, stiffening, and unresponsiveness related to stress of an absent husband. She was diagnosed with conversion fits and underlying depression.
3) Shakeela Bibi, a 19-year-old single woman, presented with breathing issues, decreased sleep, and reciting religious songs constantly, related to relationship issues. She was
Sarah, a 34-year-old teacher, has experienced chronic, remitting episodes of depression for 10 years. Her current episode involves low self-esteem, sleep problems, lack of enjoyment, suicidal thoughts, weight gain, despair, isolation, worthlessness and concentration difficulties. Previous treatments with SSRIs provided initial relief but symptoms returned. Amitriptyline was prescribed but exacerbated manic symptoms, leading to a diagnosis of bipolar disorder. Hospitalization and lithium stabilized her condition. The case highlights how bipolar disorder can initially present as depression and the importance of a thorough psychiatric history for correct diagnosis.
A 22-year-old female medical student presented with a two month history of deteriorating concentration, poor memory, and failing tests. Her mother reported disturbed behavior for a year. On examination, she displayed restless and confused behavior with an organized delusional system involving reference, persecution, and sexual delusions. A provisional diagnosis of acute psychotic episode was made, with differential diagnoses of affective disorder or schizophrenia. She was started on antipsychotics, antidepressants, iron supplements, and engaged in supportive therapy, daily activity planning, and family therapy to address biological, psychological, and social aspects of her condition.
1. Said Mohammad, an 18-year-old male from Peshawar, presented with suspiciousness, aggression, insomnia, lack of appetite, and social withdrawal over the past month.
2. His symptoms began one month ago when he started socially withdrawing and expressing beliefs that his family was plotting to kill him. Over the past three days, he became aggressive, refused to eat or sleep, and believed his family would poison him.
3. He was brought to the hospital by his family after attempts to treat him with spiritual healers were unsuccessful. His symptoms appeared to develop after recently relocating with his family due to security concerns.
The patient is a 45-year-old married female who has been experiencing psychiatric symptoms for 12 years. She initially presented with fear, talking to herself, and suspicious behavior. Medications provided minimal relief and her condition has worsened over time. She now experiences auditory hallucinations, delusions that she is being harassed, and shows unpredictable and aggressive behavior. A mental status examination revealed impaired thought processes and insight.
Somatization disorders involve physical symptoms that cannot be explained medically, and are thought to be related to psychological factors. They include somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder. The symptoms are real but are caused or exacerbated by stress and psychological issues rather than physical pathology. Treatment involves psychotherapy and helping the patient manage stress and recognize psychological contributors to their symptoms.
This document discusses several somatic symptom and dissociative disorders including somatic symptom disorder, illness anxiety disorder, conversion disorder, and their diagnostic criteria and features. Somatic symptom disorder involves physical symptoms that cause significant distress or impairment, along with excessive thoughts about the symptoms. Illness anxiety disorder involves severe health anxiety without corresponding physical symptoms. Conversion disorder was historically called hysteria and involves neurological symptoms like paralysis that cannot be explained physically.
Will talk about the severe psychological disorders-- The familiar name for all might be -"Schizophrenia" - it is not just one category but has multiple categories combined under -"Schizophrenia spectrum"
My forensic psychiatric research done in Indian jails shows most convicts under murder cases belong to schizophrenia spectrum (98% schizophrenia and 2% paranoid & schizoid personality disorders), and most have murdered their spouses, family members, friends or colleagues and surrendered themselves on the spot.
This presentation on the "Schizophrenia spectrum" has been particularly shared with you all to extend my message to help these affected people at the right time and maintaining their condition to prevent them from committing such crimes as there is no proper mental health care--Clinical, Legal or authoritative help available for convicts suffering from mental disorder.
The document describes several case studies of patients presenting with various psychological symptoms:
1) M.Zubair, a 26-year-old shopkeeper, presented with intense jerky movements related to anxiety about his upcoming marriage. He was diagnosed with conversion disorder.
2) Parveen Begum, a 35-year-old mother of 4, presented with episodes of loss of vision, stiffening, and unresponsiveness related to stress of an absent husband. She was diagnosed with conversion fits and underlying depression.
3) Shakeela Bibi, a 19-year-old single woman, presented with breathing issues, decreased sleep, and reciting religious songs constantly, related to relationship issues. She was
1. An 18-year-old male student presented with a 6-year history of repetitive obsessive thoughts and compulsive acts related to cleanliness and arranging items, as well as repetitive clicking of his pen.
2. He had been previously diagnosed with obsessive compulsive disorder but became non-compliant with medication. His symptoms intensified, interfering with his studies and causing depression and suicidal ideation, leading to 5 suicide attempts.
3. After admission, testing confirmed severe OCD and moderate depression. He was diagnosed with OCD with high suicidal risk and treated with medication, ECT, and supportive counseling. His condition improved after treatment and he was discharged with follow-up care
Biopsychosocial Model in Psychiatry- Revisited.pptxDevashish Konar
Over time our understanding of Psychiatric illnesses has undergone sea changes but yet the age old Bio-psycho-social model of etiology remains relevant. This presentation is an effort to explore the model in context of the newer developments.
1. The patient is a 29-year-old Filipino man who was admitted to Banag-Laum Home for visual hallucinations and delusions.
2. He has a history of occasional alcohol and shabu (methamphetamine) use, with his last use being days before admission.
3. A mental status exam found the patient to be oriented with normal mood, affect, speech, and thought processes. He reported previous visual and olfactory hallucinations.
A 33-year-old male presented with symptoms of loss of interest, lethargy, and reduced mental and physical well-being for the past 6-7 years. He has a family history of possible psychiatric illness in his grandfather. On examination, he displayed anxious and inappropriate behavior, impaired comprehension, rapid speech, an anxious mood, paranoid delusions, and impaired judgment and insight. He was diagnosed with paranoid schizophrenia based on his symptoms. Schizophrenia is a chronic mental disorder caused by genetic and environmental factors. It involves positive symptoms like hallucinations and delusions as well as negative symptoms and is typically treated with antipsychotic medication.
Mrs. R is a 34-year-old married Malay woman diagnosed with schizopheniform disorder who was admitted to the psychiatric ward on December 8, 2014. She has a family history of mental illness and experiences auditory hallucinations telling her to harm her son. On assessment, she shows signs of disorganized speech and thought, mood disorder, and psychotic symptoms including auditory hallucinations and paranoid delusions. Objective assessments find mild to moderate cognitive impairment and difficulties with social interaction and managing stress. She is prescribed olanzapine and clozapine and is responsive to treatment.
Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years.
Schizophrenia Spectrum & Other Psychotic Disorders for NCMHCE StudyJohn R. Williams
The document provides an overview of schizophrenia spectrum and other psychotic disorders according to the DSM-5. It discusses key features of psychotic disorders including delusions, hallucinations, and disorganized thinking. It then summarizes several psychotic disorders - brief psychotic disorder, delusional disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorder, and psychotic disorder due to another medical condition. For each disorder, it outlines diagnostic criteria and treatment approaches including medications, therapy, and monitoring.
This case involves an 85-year-old woman who was hospitalized for increased psychosis and agitation. She was diagnosed with delirium caused by multiple factors including infections, medications, and medical issues. Her delirium improved with treatment of the underlying causes. She was also found to have recurrent major depressive disorder with psychosis and late-onset Alzheimer's dementia. Her psychiatric conditions were managed with medications and non-pharmacological therapies. She was discharged to a nursing facility in a stabilized condition.
J.K. is a 34-year-old man with a 16-year history of schizophrenia who was admitted to the hospital after becoming unpredictable and threatening violence. He had been refusing medications and experiencing auditory hallucinations telling him to harm himself. Upon examination, he displayed symptoms of loose thought processes, depression, and diminished judgment. His condition is thought to have decompensated due to medication noncompliance, which has led to multiple hospital admissions in the past.
The document provides an overview of psychiatry and mental health topics. It defines mental health according to the WHO as a state of complete physical, mental, social and spiritual well-being. More than two-fifths of total disabilities worldwide are due to mental illnesses such as schizophrenia, depression, and substance abuse disorders. It discusses classification systems for psychiatric disorders, biological, psychological and social factors in mental illnesses, and specific conditions such as mood disorders, psychotic disorders, personality disorders, and more.
This document provides an overview of a presentation on sexuality and sex therapy. It includes:
- Definitions of key terms related to sexuality like sexuality, gender roles, and gender identity.
- Descriptions of the phases of the human sexual response cycle according to Masters and Johnson and Kaplan.
- Discussions of common sexual dysfunctions like lack of sexual desire, erectile dysfunction, and premature ejaculation.
- Overviews of paraphilias and sexual deviations.
- Brief histories of perspectives on sexuality from Freud, Ellis, Kinsey, and Masters and Johnson.
- Descriptions of common techniques in sex therapy like history taking, sensate focus exercises, and the PL
This case presentation describes a 57-year-old man with a 2-3 year history of symptoms of sadness, disturbed sleep, irritability, and muttering to himself. His symptoms started gradually without a clear stressor. After a thorough examination, he was diagnosed with agitated depression. He was treated on an outpatient basis with escitalopram and lorazepam, along with family psychoeducation and relaxation techniques. Within 6 weeks of treatment, he showed over 80% improvement in his symptoms.
This document provides an overview of psychiatry case taking and examination, including history taking and mental status examination (MSE). It discusses the purpose and general principles of history taking, as well as how to structure the interview room and questions. It then describes how to obtain information on a patient's identifying data, chief complaints, history of present illness, past history, family history, personal history, and pre-morbid personality. Finally, it outlines the components of the MSE including general appearance, psychomotor activity, speech, mood, thought, perception, and cognitive functions.
DBT is a treatment for borderline personality disorder that combines cognitive behavioral therapy with mindfulness practices. It aims to help patients regulate their emotions and improve their interpersonal relationships through weekly skills training groups, individual therapy sessions, phone coaching, and therapist consultation meetings. Key aspects of DBT include balancing acceptance of patients with strategies to induce change, validating patients' experiences, and teaching skills for mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation.
Somatoform disorders involve physical symptoms that cannot be fully explained by medical factors and cause significant distress. Somatic symptom disorder involves preoccupation with fears of illness for 6+ months. Illness anxiety disorder is a preoccupation with being sick without actual symptoms. Conversion disorder involves psychological stress converting to motor or sensory symptoms. Treatment focuses on reassurance, psychotherapy, and addressing underlying psychiatric conditions.
This document provides an outline and overview of somatic symptom and related disorders according to DSM-5 criteria, including Somatic Symptom Disorder, Conversion Disorder, and Somatic Symptom Disorder with Predominant Pain. It discusses the changes made from DSM-IV to DSM-5, epidemiology, etiology, differential diagnosis, clinical features, and treatment approaches for each disorder. The document is intended to educate psychiatry residents on consultation-liaison psychiatry and the somatic symptom disorders.
The document discusses several somatoform and somatic symptom disorders from the DSM-IV and DSM-V. It summarizes the key disorders including: somatic symptom disorder, which involves preoccupation with physical symptoms and their severity; conversion disorder, where neurological or sensory symptoms cannot be explained medically and may be psychological in origin; and illness anxiety disorder, previously known as hypochondriasis, involving severe anxiety and worry about having a serious illness. It provides details on diagnostic criteria, epidemiology, clinical features, etiology, course, and treatment approaches for these disorders.
1. An 18-year-old male student presented with a 6-year history of repetitive obsessive thoughts and compulsive acts related to cleanliness and arranging items, as well as repetitive clicking of his pen.
2. He had been previously diagnosed with obsessive compulsive disorder but became non-compliant with medication. His symptoms intensified, interfering with his studies and causing depression and suicidal ideation, leading to 5 suicide attempts.
3. After admission, testing confirmed severe OCD and moderate depression. He was diagnosed with OCD with high suicidal risk and treated with medication, ECT, and supportive counseling. His condition improved after treatment and he was discharged with follow-up care
Biopsychosocial Model in Psychiatry- Revisited.pptxDevashish Konar
Over time our understanding of Psychiatric illnesses has undergone sea changes but yet the age old Bio-psycho-social model of etiology remains relevant. This presentation is an effort to explore the model in context of the newer developments.
1. The patient is a 29-year-old Filipino man who was admitted to Banag-Laum Home for visual hallucinations and delusions.
2. He has a history of occasional alcohol and shabu (methamphetamine) use, with his last use being days before admission.
3. A mental status exam found the patient to be oriented with normal mood, affect, speech, and thought processes. He reported previous visual and olfactory hallucinations.
A 33-year-old male presented with symptoms of loss of interest, lethargy, and reduced mental and physical well-being for the past 6-7 years. He has a family history of possible psychiatric illness in his grandfather. On examination, he displayed anxious and inappropriate behavior, impaired comprehension, rapid speech, an anxious mood, paranoid delusions, and impaired judgment and insight. He was diagnosed with paranoid schizophrenia based on his symptoms. Schizophrenia is a chronic mental disorder caused by genetic and environmental factors. It involves positive symptoms like hallucinations and delusions as well as negative symptoms and is typically treated with antipsychotic medication.
Mrs. R is a 34-year-old married Malay woman diagnosed with schizopheniform disorder who was admitted to the psychiatric ward on December 8, 2014. She has a family history of mental illness and experiences auditory hallucinations telling her to harm her son. On assessment, she shows signs of disorganized speech and thought, mood disorder, and psychotic symptoms including auditory hallucinations and paranoid delusions. Objective assessments find mild to moderate cognitive impairment and difficulties with social interaction and managing stress. She is prescribed olanzapine and clozapine and is responsive to treatment.
Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years.
Schizophrenia Spectrum & Other Psychotic Disorders for NCMHCE StudyJohn R. Williams
The document provides an overview of schizophrenia spectrum and other psychotic disorders according to the DSM-5. It discusses key features of psychotic disorders including delusions, hallucinations, and disorganized thinking. It then summarizes several psychotic disorders - brief psychotic disorder, delusional disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorder, and psychotic disorder due to another medical condition. For each disorder, it outlines diagnostic criteria and treatment approaches including medications, therapy, and monitoring.
This case involves an 85-year-old woman who was hospitalized for increased psychosis and agitation. She was diagnosed with delirium caused by multiple factors including infections, medications, and medical issues. Her delirium improved with treatment of the underlying causes. She was also found to have recurrent major depressive disorder with psychosis and late-onset Alzheimer's dementia. Her psychiatric conditions were managed with medications and non-pharmacological therapies. She was discharged to a nursing facility in a stabilized condition.
J.K. is a 34-year-old man with a 16-year history of schizophrenia who was admitted to the hospital after becoming unpredictable and threatening violence. He had been refusing medications and experiencing auditory hallucinations telling him to harm himself. Upon examination, he displayed symptoms of loose thought processes, depression, and diminished judgment. His condition is thought to have decompensated due to medication noncompliance, which has led to multiple hospital admissions in the past.
The document provides an overview of psychiatry and mental health topics. It defines mental health according to the WHO as a state of complete physical, mental, social and spiritual well-being. More than two-fifths of total disabilities worldwide are due to mental illnesses such as schizophrenia, depression, and substance abuse disorders. It discusses classification systems for psychiatric disorders, biological, psychological and social factors in mental illnesses, and specific conditions such as mood disorders, psychotic disorders, personality disorders, and more.
This document provides an overview of a presentation on sexuality and sex therapy. It includes:
- Definitions of key terms related to sexuality like sexuality, gender roles, and gender identity.
- Descriptions of the phases of the human sexual response cycle according to Masters and Johnson and Kaplan.
- Discussions of common sexual dysfunctions like lack of sexual desire, erectile dysfunction, and premature ejaculation.
- Overviews of paraphilias and sexual deviations.
- Brief histories of perspectives on sexuality from Freud, Ellis, Kinsey, and Masters and Johnson.
- Descriptions of common techniques in sex therapy like history taking, sensate focus exercises, and the PL
This case presentation describes a 57-year-old man with a 2-3 year history of symptoms of sadness, disturbed sleep, irritability, and muttering to himself. His symptoms started gradually without a clear stressor. After a thorough examination, he was diagnosed with agitated depression. He was treated on an outpatient basis with escitalopram and lorazepam, along with family psychoeducation and relaxation techniques. Within 6 weeks of treatment, he showed over 80% improvement in his symptoms.
This document provides an overview of psychiatry case taking and examination, including history taking and mental status examination (MSE). It discusses the purpose and general principles of history taking, as well as how to structure the interview room and questions. It then describes how to obtain information on a patient's identifying data, chief complaints, history of present illness, past history, family history, personal history, and pre-morbid personality. Finally, it outlines the components of the MSE including general appearance, psychomotor activity, speech, mood, thought, perception, and cognitive functions.
DBT is a treatment for borderline personality disorder that combines cognitive behavioral therapy with mindfulness practices. It aims to help patients regulate their emotions and improve their interpersonal relationships through weekly skills training groups, individual therapy sessions, phone coaching, and therapist consultation meetings. Key aspects of DBT include balancing acceptance of patients with strategies to induce change, validating patients' experiences, and teaching skills for mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation.
Somatoform disorders involve physical symptoms that cannot be fully explained by medical factors and cause significant distress. Somatic symptom disorder involves preoccupation with fears of illness for 6+ months. Illness anxiety disorder is a preoccupation with being sick without actual symptoms. Conversion disorder involves psychological stress converting to motor or sensory symptoms. Treatment focuses on reassurance, psychotherapy, and addressing underlying psychiatric conditions.
This document provides an outline and overview of somatic symptom and related disorders according to DSM-5 criteria, including Somatic Symptom Disorder, Conversion Disorder, and Somatic Symptom Disorder with Predominant Pain. It discusses the changes made from DSM-IV to DSM-5, epidemiology, etiology, differential diagnosis, clinical features, and treatment approaches for each disorder. The document is intended to educate psychiatry residents on consultation-liaison psychiatry and the somatic symptom disorders.
The document discusses several somatoform and somatic symptom disorders from the DSM-IV and DSM-V. It summarizes the key disorders including: somatic symptom disorder, which involves preoccupation with physical symptoms and their severity; conversion disorder, where neurological or sensory symptoms cannot be explained medically and may be psychological in origin; and illness anxiety disorder, previously known as hypochondriasis, involving severe anxiety and worry about having a serious illness. It provides details on diagnostic criteria, epidemiology, clinical features, etiology, course, and treatment approaches for these disorders.
This document discusses somatic symptom and related disorders. It defines psychological factors that can affect medical conditions by exacerbating symptoms or interfering with treatment. It provides qualifiers to describe the severity of these psychological influences. The key features and differential diagnosis of various somatic symptom disorders are outlined, including somatic symptom disorder, illness anxiety disorder, and factitious disorders. Screening tools like the PHQ-15 and SSS-8 are presented. Treatment approaches are emphasized, including scheduling regular appointments, educating patients, evaluating somatic symptoms, treating comorbid conditions, and using cognitive behavioral therapy and medication.
The term “psychosomatic disorder” is mainly used to mean “a physical disease that is thought to be caused, or made worse, by mental factors.” ... For example, chest pain may be caused by stress and no physical disease can be found.
Diagnosis and Treatment of Psychosomatic Disorder (Educational Slides)Andri Andri
This is a standard presentation for teaching medical students and colleagues about psychosomatic disorder, its diagnosis and therapy. We hope by reading this slides, you will understand the nature of psychosomatic disorder and its current approach in therapy
This document discusses somatization disorder, including its definition, symptoms, diagnosis, treatment, and prognosis. Somatization disorder involves a person experiencing physical symptoms that cannot be explained medically, and it affects their daily functioning. Treatment involves developing a trusting doctor-patient relationship, avoiding unnecessary medical tests, and utilizing psychotherapy and lifestyle changes like exercise to help manage stress and underlying mental health conditions. The prognosis is generally improved with a multidisciplinary treatment approach.
This document discusses medically unexplained physical symptoms (MUPS) and somatic symptom disorder. It defines MUPS as physical symptoms that exist without objective medical findings or explanations. Somatic symptom disorder is characterized by physical symptoms caused by psychological or emotional distress. The document reviews the epidemiology, risk factors, clinical features, diagnostic criteria, cultural influences, and approaches for evaluating and treating patients with somatic symptom disorder.
This document discusses functional somatic syndromes (FSS), conditions characterized by medically unexplained physical symptoms. It provides an overview of several FSS including fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome. While the pathophysiology of FSS is not fully understood, they often involve central sensitization and are commonly associated with psychiatric comorbidities. The document emphasizes taking a biopsychosocial approach to FSS that focuses on function rather than symptoms, includes limited reassurance and cognitive behavioral therapy, and considers potential psychosocial contributing factors. Proper evaluation involves screening for medical and psychiatric disorders, with treatment aiming to improve functioning rather than solely reducing symptoms.
Somatoform disorders are characterized by physical symptoms that cannot be fully explained by medical factors. They include somatic symptom disorder, conversion disorder, and illness anxiety disorder. Somatic symptom disorder involves multiple somatic complaints and excessive thoughts about health. Conversion disorder involves neurological symptoms with no medical cause. Illness anxiety disorder involves excessive worry about having a serious illness. These disorders are thought to arise from psychological factors influencing mind-body interactions and are typically treated with psychotherapy.
This document discusses types of mental illness and modalities of treatment. It outlines the objectives of identifying, screening, and treating common mental disorders like depressive disorders, anxiety disorders, and somatization disorder, as well as severe mental disorders and substance use disorders. It then describes the common mental disorders in more detail, including their clinical features and differential diagnoses. It provides guidelines for treatment of common mental disorders focusing on pharmacological interventions like SSRIs, SNRIs, and TCAs. The document emphasizes screening patients for mental illness, identifying the disorder, providing appropriate treatment, and knowing when to refer to a higher level of care.
Medically Unexplained Symptoms final 2 15 AUG 2022.pptxRibhavGupta13
The document discusses medically unexplained symptoms and provides a history and overview of concepts related to somatoform disorders. It summarizes key terms and concepts that have been used over time, such as hysteria and hypochondriasis. Functional somatic syndromes and changes in diagnostic criteria from DSM-IV to DSM-5 are summarized. Specific somatic symptom and related disorders like somatic symptom disorder and illness anxiety disorder are briefly described. Etiology, assessment, treatment including CBT and pharmacotherapy, and factitious disorder are highlighted at a high level.
Interface between Psychiatry and Medicine.pptxCalebMucho
This document discusses the relationship between mental and physical health. It describes how psychiatric diagnoses are made based on symptoms and syndromes rather than identifiable bodily pathology like medical diagnoses. Conditions involving bodily symptoms without pathology, like somatic symptom disorder, are reviewed. The management of these disorders focuses on ruling out medical causes and reducing unnecessary medical interventions. Various medical conditions that are associated with increased risk of psychiatric disorders are also summarized, including neurological, cardiovascular, endocrine, and renal disorders as well as infections and cancer.
Somatoform disorders are a group of mental disorders characterized by physical symptoms that cannot be fully explained by a general medical condition. Key features include physical complaints with no adequate medical explanation that cause significant distress or impairment. Somatization disorder involves multiple somatic complaints over several years, while conversion disorder involves neurological symptoms that are psychologically caused. Hypochondriasis involves excessive worry about having a serious illness despite medical reassurance. Treatment focuses on psychotherapy and treating any underlying mental health conditions.
Somatic symptom disorder is a mental illness that causes distressing physical symptoms without a clear medical cause. Treatment focuses on improving daily functioning rather than just symptoms, and may include therapy, stress reduction, and addressing any underlying mental health conditions. Hypochondriasis involves a persistent fear of having a serious illness despite reassurance. Illness anxiety disorder involves excessive worry about personal health without clear physical symptoms. These somatic symptom disorders can be chronic and difficult to treat, often requiring therapy and management of anxiety.
iCAAD London 2019 - Dr James Stallard - THE REVOLVING DOOR - PSYCHIATRY IN T...iCAADEvents
Functional, or medically unexplained, symptoms are some of the most complex and controversial problems presenting to clinicians. Overuse of opiates for pains which never get better, demands for operations which aren't necessary and long stays in hospital. How does a psychiatrist working on the frontline of the NHS steer treating teams and patients towards better outcomes?
Depression commonly occurs in medical settings and can be caused by medical illnesses or their treatments. It is important to thoroughly evaluate depression in medically ill patients, as their symptoms may overlap with medical conditions or be side effects of medications. Treatment of depression in this population requires considering any interactions between antidepressants and other drugs, and utilizing biological, psychological, and educational approaches. Managing both the medical and psychiatric conditions is needed to improve outcomes.
This document discusses depression in medical settings. It begins by classifying different types of depressive disorders and then discusses the prevalence of depression across various medical conditions such as heart disease, cancer, diabetes, and neurological diseases. It notes the difficulties in diagnosing depression in medically ill patients, as medical symptoms can overlap with depressive symptoms. The document then covers evaluating depression in both inpatient and outpatient medical settings. It discusses differential diagnoses and conditions that can mimic depression. Finally, it briefly touches on the impact depression can have for those with chronic medical illnesses.
Depression: What Is It and What Are My Treatment Options? (Community Lecture)Summit Health
This document discusses depression, including its definition, statistics, types, causes, consequences, role of neurotransmitters, treatment options like medication and cognitive behavioral therapy. It defines depression and differentiates it from normal sadness. It covers diagnostic criteria, risk factors, and treatments including antidepressant medications, electroconvulsive therapy, light therapy, and cognitive behavioral therapy. Relapse prevention and the importance of continued treatment are also discussed.
multidimensional approach to impulsivity.pptxehab elbaz
understanding impulsivity and its relation to psychiatric disorders. history of the concept and evidence based pharmacological and psychological interventions
The document discusses the history and evolution of case formulation in psychiatry. It originated from Adolf Meyer's holistic approach in the early 1900s and was further developed by George Kelly in the 1950s. Key figures like George Engel promoted biopsychosocial formulations. While important, formulations are still confusing and not uniformly understood. The document outlines core components and functions of formulations, including guiding treatment and integrating diverse clinical information.
depression in intellectual disabilitiy.pptxehab elbaz
1) The document describes a case of a 34-year-old male patient with intellectual disabilities who was referred for treatment of depression. He had a history of cerebral palsy, brain cysts, hydrocephalus, and epilepsy since birth.
2) After his brother traveled abroad for work, the patient became withdrawn, aggressive, and refused to eat, drink, or get out of bed. He was diagnosed with catatonia.
3) Treating the patient's condition proved challenging due to his intellectual disabilities and other medical issues. He did not improve with benzodiazepines or antipsychotics. ECT was considered but he suffered cardiac arrest before it could be administered.
The document discusses addiction replacement therapy (also known as opioid substitution therapy) for treating opioid use disorder. It begins by outlining the objectives and magnitude of the global and Egyptian opioid problems. It then describes medication-assisted treatment using opioid agonists/antagonists like methadone and buprenorphine. The benefits of opioid substitution therapy include reducing illegal opioid use and associated harms while increasing social functioning. Common myths about substitution therapy are addressed. Treatment algorithms are provided to guide patient assessment and selection of optimal replacement therapies like methadone, buprenorphine or naltrexone based on their different pharmacological profiles and patient characteristics.
Focus on long acting opioid substitution therapy.pptxehab elbaz
Long-acting buprenorphine injections like Buvidal can help address some of the limitations of daily-dosed opioid substitution therapies for opioid dependence. Evidence shows that Buvidal provides sustained suppression of withdrawal symptoms and drug cravings from the first dose. It also has favorable retention rates and safety profiles in both short-term and long-term studies compared to sublingual buprenorphine. Buvidal has the potential to improve outcomes for opioid dependence by offering more individualized treatment through less frequent dosing than daily options.
Dissociation is characterized by a disruption in consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Dissociative disorders include Dissociative Identity Disorder, Dissociative Amnesia, Depersonalization/Derealization Disorder, Other Specified Dissociative Disorder, and Unspecified Dissociative Disorder. Lifetime prevalence of dissociation and dissociative disorders is around 10% in clinical and community populations. Dissociation exists on a continuum from normal experiences like daydreaming to pathological dissociation as seen in dissociative disorders. Dissociation is often associated with and can be explained as a response to traumatic stress.
Use of smartphone apps in psychotherapy ehab elbaz
The document discusses the use of smartphone apps in psychotherapy. It answers four questions: 1) Barriers to psychotherapy include costs, time, stigma and access issues. 2) Studies show smartphone apps can effectively treat depression, anxiety, and other issues, especially when combined with guidance. 3) Common CBT app features include cognitive restructuring, education on disorders, and suicide risk resources. 4) Few apps are available for Arab populations, most provide general mental health information or alternative treatments like herbal medicine.
This document describes models and processes in psychosomatic medicine and consultation-liaison psychiatry. It discusses different models including traditional consultation upon request and liaison psychiatry. It outlines the essential tasks of consultation-liaison psychiatrists including assessment, management planning, education, and facilitating understanding between medical teams and patients. The document also reviews the steps in a psychiatric consultation and elements of the written consultation note. Finally, it discusses different methods of integrated mental health care programs within medical settings.
Group psychotherapy versus twelve steps program , similarities and differencesehab elbaz
Both group psychotherapy and 12-step programs aim to help people with addiction issues. They share some similarities, such as relying on group cohesion and participant collaboration, using experiential learning, and encouraging honest self-disclosure. However, they also have some key differences. Group psychotherapy is a therapeutic program run by professionals, while 12-step programs are spiritual programs run by members. Group psychotherapy focuses more on managing conflicts between members during sessions. 12-step programs encourage contact between members outside meetings and restrict boundaries to minimize conflicts. Both approaches ultimately promote learning, growth, and positive change.
Patient safety involves avoiding preventable harm caused by errors in healthcare. There are different types of medical errors from errors to adverse events. A sentinel event is an unexpected occurrence that causes death or serious injury. Near misses refer to errors that could have caused harm but did not. A culture of safety depends on values, attitudes, behaviors and other factors that promote commitment to safety. Proper identification of patients, effective communication, safe practices for high-risk medications, and protocols for surgery are important for quality care and patient safety.
This document summarizes an orientation program at GAHAR Hospital that covers leadership and workforce requirements. The agenda includes reviewing GAHAR's leadership manual, job descriptions, strategic planning policy, and workforce requirements. For leadership, the manual, job descriptions, strategic planning components, and related policies are presented. Workforce topics include staffing plans, recruitment, credentialing, competencies, privileging, employee manuals, bylaws, health programs, and training needs. The objectives are to identify and implement GAHAR's leadership and workforce requirements and adopt their implementation.
This document outlines the agenda and objectives for Day 3 of the Orientation Program on GAHAR Hospital. The agenda includes sessions on the GAHAR Operating Manual guidelines, the hospital overview, management of the information system, medical records, provision of care and services, quality management and patient safety, infection prevention and control, patient and family education, patient and family rights, social care, anesthesia, operative care, critical care units, labor and delivery, dialysis, emergency room, radiology services, burn unit, and oncology and radiotherapy. The objectives are to identify and implement the GAHAR operating manual guidelines and respect their importance, and by the end of the day for participants to be able to do so.
This document provides an agenda and materials for an orientation program on safety standards at GAHAR Hospital. It includes sessions on medication management safety standards, operative and invasive procedure safety standards, and environmental safety standards. The objectives are to help participants identify and implement relevant GAHAR standards to minimize safety risks and harm to patients. The document reviews several specific standards for policies, procedures, labeling, documentation, and checklists to ensure correct patient identification, medication reconciliation, and availability of necessary documents and equipment for procedures.
The document outlines the requirements and agenda for an orientation program on GAHAR Hospital. It discusses the registration requirements for hospitals, including licensure requirements, national safety requirements, operating manual guidelines, leadership requirements, and workforce requirements. The agenda spans 4 days and covers topics such as the GAHAR registration system, national safety standards, operating manual guidelines, leadership manuals and policies, and workforce requirements. Session objectives are provided for each day.
This document provides an introduction to the JCI standards for accreditation. It defines key terms like quality and standards. It describes the accreditation process and outlines the chapters covered in the JCI standards, including patient care, health organization management, and academic medical centers. It discusses developing policies and procedures, conducting a baseline assessment, and creating an action plan to prepare for accreditation over an 18-24 month period. The goals are to establish a culture of safety, continually improve quality, and make data-driven decisions.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
2. Outline
■ Somatic Symptom Disorder (300.82)
■ Other Specified Somatic Symptom and Related Disorder (300.89)
■ Unspecified Somatic Symptom and Related Disorder (300.82)
■ Conversion Disorder (300.11)
■ Illness Anxiety Disorder (300.7)
■ Factitious Disorder (300.19)
■ Psychological Factors Affecting Other Medical Conditions (316)
2
3. Disclaimer
■ Much of the data provided in this lecture is based on equivalent diagnosis from
DSM-IV TR
■ Most data is applicable and time will tell if significant shifts in data occur based
on diagnosis changes (expect very mild changes if any)
3
4. Somatic Symptom and Related
Disorders
■ Somatic Symptom Disorder
– Physical symptoms that prompt the sufferer to seek health care but remain
unexplained after an appropriate evaluation (Richardson and Engel, 2004)
– Specify:
■ With predominant pain
■ Persistent
■ Current severity: Mild, Moderate, Severe
4
5. Somatic Symptom and Related
Disorders
■ Somatic Symptom Disorder – One syndrome or many?
– Some authors have suggested that the precise diagnosis given
depends more on the diagnosing physician’s specialty than on
any actual differences between the syndromes
– Categorization
■ Psychiatric – derived from primary psychiatric etiology (i.e. an anxiety
disorder)
■ Hypothetical syndromes based on diagnostic criteria
■ Social – derived from past trauma, exposure, or cultural differences in
expression
5
6. Somatic Symptom and Related
Disorders
■ Somatic Symptom Disorder – One syndrome or many?
– Internal Medicine
■ Chronic fatigue
– Gynecology
■ Chronic pelvic pain
– ENT
■ Idiopathic tinnitus
– Dentistry
■ Temporomandibular dysfunction
– Rheumatology
■ Fibromyalgia
– GI
■ Irritable bowel syndrome
– Neurology
■ Nonepileptic seizures
6
7. Somatic Symptom and Related
Disorders
■ Somatic Symptom Disorder – Consequences
– Impaired physician-patient relationship
■ Physician frustration
– 1/6 primary care visits are considered “difficult”
■ Hahn, 2001
– “Dose-response” relationship between symptoms and physician frustration
■ 0-1 symptom 6% difficult
■ 2-5 symptoms 13% difficult
■ 6-9 symptoms 23% difficult
■ 10 or more symptoms 36% difficult
■ Patient dissatisfaction
7
8. Somatic Symptom and Related
Disorders
■ Somatic Symptom Disorder – Consequences
– Psychosocial distress
– Decreased quality of life
– Increased rates of depression and anxiety
– Increased health care utilization
■ Increased utilization leads to more harm
■ Patient dissatisfaction
■ Higher medical costs
■ Provider burnout
8
9. DSM-5
_________________________________________________________________
Why Change?
■ Over-emphasis on medically unexplained symptoms (MUS)
■ Shift from “dx of exclusion” to neurologic exam and positive symptom criteria
■ Elimination of pejorative labels
■ More functional approach
■ Mind-body dualism
■ Not used by clinicians
■ Criteria were too sensitive and too specific
Emphasis on disproportionate thoughts, feelings, and behaviors that accompany
and are related to physical symptoms
10. Old Diagnoses; New Addresses
Body Dysmorphic
Disorder
Factitious Disorder
Psychological factors
affecting medical
condition
Now included
with the other
Somatic
Symptom
Disorders
Moved to the obsessive
compulsive and related
disorders
11. All That is Old is New Again
_______________________________________
The New Diagnoses
Somatization Disorder
________________
Undifferentiated Somatoform
Disorder
__________________
Pain Disorder
Hypochondriasis
Somatic Symptom
Disorder
Illness
Anxiety
Disorder
With somatic symptoms
Without somatic
symptoms
13. DSM IV DSM 5
■ Somatization disorder Somatic Symptom Disorder
■ Conversion disorder Conversion Disorder
– Same but shift in focus to positive signs and neuro exam
■ Pain disorder Somatic Symptom Disorder with predominant pain
– also consider: Psychological Factors affecting Other Medical Conditions VS Adjustment Disorder
■ Hypochondriasis Illness Anxiety Disorder
■ Body Dysmorphic disorder moved to Obsessive-Compulsive and Related disorders
■ Undifferentiated somatoform disorder Other Specified Somatic Symptom and Related
Disorder
■ Somatoform disorder NOS Unspecified Somatic Symptom and Related Disorder
13
14. Somatic Symptom Disorder
■ Generalities
– 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
■ Specify:
– With predominant pain
– Persistent
– Current severity: Mild, Moderate, Severe
14
15. Somatic Symptom Disorder
■ Alexithymia
– Term coined by Sifneos in 1973
– Individuals who have difficulties expressing emotions verbally
– Correlates positively with:
■ Depression
■ Somatization
■ Hypochondriasis
15
16. Somatic Symptom Disorder
■ DSM-5 Criteria
– 1+ somatic symptoms that are distressing or result in significant
disruption of daily life
– Excessive thoughts, feelings, or behaviors related to the somatic
symptoms or associated health concerns as manifested by at least 1 of
the following:
■ Disproportionate and persistent thoughts about the seriousness of one’s
symptoms
■ Persistently high level of anxiety about health or symptoms
■ Excessive time and energy devoted to these symptoms or health concerns
– Typically > 6 months
16
17. Somatic Symptom Disorder
■ Epidemiology (based on DSM-IV diagnosis for Somatization Disorder)
– Somatization disorder
■ General population: 0.01%
■ Primary care setting: 3%
– Subsyndromal somatization disorder
■ General population: 11%
■ Primary care setting: 20%
17
18. Somatic Symptom Disorder
■ Etiologies
– Defense mechanisms – symptoms gaurd pt from experiencing
thoughts/feelings
– Genetic & family studies
– Behavioral – trained patterns of action that manifest throughout a pt’s
development
– Early life experiences – ex: trauma
– Personality – circumstances in development can manifest in particular
patterns of coping and interrelatedness
18
19. Somatic Symptom Disorder
■ Differential diagnosis
– Medical conditions
■ Disorders with transient nonspecific symptoms
– Psychiatric conditions
■ Other somatoform disorders
■ Depression
■ Anxiety
– Varies by symptom
■ Ex: Chronic fatigue vs hypothyroidism
■ Ex: Irritable bowel syndrome vs allergy
■ Ex: Nonepileptic seizures vs epileptic seizures
19
20. Somatic Symptom Disorder
■ Clinical features
– Large number of outpatient visits
– Frequent hospitalizations
– Repetitive subspecialty referrals
– Large number of diagnoses
– Multiple medications
– Multiple allergies
20
21. Somatic Symptom Disorder
■ Differential diagnosis (continued)
– The three features that most suggest a diagnosis of somatic symptom
disorder instead of another medical disorder are
■ Involvement of multiple organ systems
■ Early onset and chronic course without development of physical signs or
structural abnormalities
■ Absence of laboratory abnormalities that are characteristic of the suggested
medical condition
21
22. Somatic Symptom Disorder
■ Differential diagnosis
– “Psychologization” may not entirely explain somatic symptoms either
■ Many patients have no other psychiatric diagnosis
■ Directionality is unclear
■ Even when physical symptoms respond to psychological treatments the effect
size may be less than for depression
22
23. Somatic Symptom Disorder
■ General 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
23
24. Somatic Symptom Disorder
■ General treatment issues:
– Is diagnostic testing therapeutic?
■ Noncardiac chest pain (Sox 1981)
– ECG vs. no test
■ More satisfied and less disabled at 3-weeks, but no difference at 4-
month follow-up
■ Headache (Howard 2005)
– Ct scan of brain
■ Less worried at 3 month, but not at 1 year
■ So… Limit work-ups to objective findings
24
25. Somatic Symptom Disorder
■ Specific treatments
– Psychotherapy
■ 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
25
26. Somatic Symptom Disorder
■ Specific treatments
– Psychopharmacology
■ Antidepressants have shown inconsistent results
■ Antidepressants have limitations in treating
– Partial response instead of remission
– Higher discontinuation rates
■ Sensitive to side effects – “nocebo”
■ Attribution to physical, whereas antidepressants suggest psychiatric –
risk of invalidation
■ Unknown long-term efficacy
26
27. Somatic Symptom Disorder
■ Nonspecific treatments
– Reassurance
■ Concluding the visit in a positive and reassuring manner has shown benefit (Kathol,
1997)
■ Reassure regarding fears of abandonment
– Reattribution
■ Broadening the agenda to include both physical and psychological factors may be
beneficial (Fink 2002)
– Normalization
■ Stating that one’s test are “normal” or “everything is fine” has not been effective
■ Need to address the patients concern(s) (Knipschild, 2005)
■ Reassure ongoing efforts to address concerns
27
28. Conversion Disorder
■ Definition
– One or more symptoms involving voluntary motor or sensory function that
suggest a medical condition
– Psychological factors are judged to be associated with the symptom
– Not intentionally produced or feigned
28
29. Conversion
(Functional Neurological Symptoms Disorder)
■ One or more symptoms of altered voluntary motor or sensory
function.
■ Clinical findings provide evidence of a mismatch between the
symptom and recognized neurological 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 functioning or warrants medical evaluation.
29
30. Conversion Disorder
■ The theoretical goal of a conversion symptom
– Symbolic resolution of an unconscious conflict in an attempt to keep the
conflicting memories out of consciousness
30
31. Conversion Disorder
■ Clinical subtypes (specify)
– With weakness or paralysis
– With abnormal movement
– With swallowing symptoms
– With speech symptom
– With attacks or seizures
– With anesthesia or sensory loss
– With special sensory symptom
– With mixed symptoms
31
33. Conversion Disorder
■ Clinical features
– Symptoms likely to occur following stress
– Symptoms tend to conform to patients understanding of neurology
– Inconsistent physical exam
33
34. Conversion Disorder
■ Concern of misdiagnosis
– Slater (1965) reported a misdiagnosis rate of 33%
■ The article warned that the diagnosis of “hysteria” was nothing more
than a “delusion and a snare.”
– Stone et al (2005) reported a significant decline in
misdiagnosis from the 1950s to the present day
■ 1950’s – 29%, 1960’s – 17%, 1970-90’s – 4%
■ Authors felt that this decline was likely due to improvements in study
quality, rather than improvements in diagnostic modalities
34
35. Conversion Disorder
■ Functional Neuroimaging
– Hysterical paralysis
■ Decreased activity in frontal and subcortical circuits involved in motor
control
– Hysterical anesthesia
■ Decreased activity in somatosensory cortices
– Hysterical blindness
■ Decreased activity in visual cortex
– Some studies have shown increased activity in limbic regions
35
36. Conversion Disorder
■ Treatment
– General/conservative
■ Reassurance
– Addressing stressors
– Protective environment
– Appropriate workup has been done and full recovery is expected
■ Physical and occupation therapy
– Psychotherapies
– Amytal interview
– Hypnosis
36
37. Conversion Disorder
■ Prognosis
– Good prognosis
■ Onset following a clear stressor
■ Prompt treatment
■ Symptoms or paralysis, aphonia and blindness
– Poor prognosis
■ Delayed treatment
■ Symptoms of seizures or tremor
37
38. Somatic Symptom Disorder
with Predominant Pain
■ Definition
– Pain is the predominant focus of 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
38
39. Somatic Symptom Disorder
with Predominant Pain
■ Clinical features
– Pain may take various forms
– Pain is severe and constant
– Pain may be disproportionate to underlying condition
– Psychological factors predominate
– Pain is often the main focus of the patient’s life
– There are concerns about the diagnostic validity of this somatoform disorder
39
41. Somatic Symptom Disorder
with Predominant Pain
■ Treatment
– General
■ Stress an understanding that the pain is real
■ Goal is likely an improvement in functioning rather than a complete relief of pain
– Cognitive-behavioral therapy
■ Relaxation therapy
■ Biofeedback
– Hypnosis
– Pharmacotherapy
41
42. Somatic Symptom Disorder
with Predominant Pain
■ Prognosis
– Poor prognosis
■ Pre-existing character pathology
■ Pending litigation
■ Use of addictive substances
■ Prolonged history of pain complaints
– Good prognosis
■ Resolution of litigation
■ Prompt treatment
42
43. Illness Anxiety Disorder
■ Definition
– Preoccupation with fears of having a serious illness that does
not respond to reassurance after appropriate medical work-up.
■ Epidemiology
– General population: ??
– Medical clinic population: 4-6%
– Medical students: 3%
43
44. Illness Anxiety Disorder
Criteria
■ 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 the preoccupation is excessive.
■ There is a high level of anxiety about health.
■ The individual performs excessive health-related behaviors or exhibits maladaptive
health-related avoidance.
■ Illness preoccupation has been present for >6 months, but the specific illness that is
feared may change.
■ The illness-related preoccupation is not better explained by another mental disorder.
44
45. Illness Anxiety Disorder
■ Clinical features
– Bodily preoccupation
– Disease phobia
– Disease conviction
– Onset in early adulthood
– Chronic with waxing and waning of symptoms
45
46. Illness Anxiety Disorder
■ Etiologies
– Psychodynamic model
■ Symptoms can be seen as a “defense against guilt”
– Cognitive-behavioral model
■ Misinterpretation of harmless bodily symptoms
■ “Better safe than sorry”
– Physiologic model
■ Low thresholds for, and low tolerance of, physical symptoms
46
47. Illness Anxiety Disorder
■ Treatment
– General aspects
■ Establishment of trust
■ History taking
■ Identification of stressors
■ Education
– Cognitive-behavioral therapy
– Supportive therapy
– Pharmacotherapy
■ Serotonergic meds appear to most beneficial
47
48. Factitious Disorder
■ Definition
– Intentionally exaggerates or induces signs and symptoms of illness.
– Motivation is to assume the sick role
– Other incentives for the illness inducing behavior are absent
■ Criteria
– Falsification of physical or psychological signs or symptoms
– Induction of injury or disease
– Presents self as ill, impaired, or injured
– Deceptive behavior in the absence of external rewards
– Not better explained by a mental disorder
48
49. Factitious Disorder
■ Specify Source
– Imposed on Self
– Imposed on Another (the perpetrator, not the victim, receives the dx)
■ Specify Course
– Single Episode
– Recurrent Episodes (2+ events)
49
50. Factitious Disorder
■ Epidemiology
– Prevalence in general population is unknown
– Diagnosed in about 1% of patients seen in psychiatric consultation in
general hospitals
■ Likely higher in referral centers
50
51. Factitious Disorder
■ Postulated Etiologies
– 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
51
52. Factitious Disorder
■ Continuum of severity
– Munchausen syndrome
■ 10% of factitious disorder patients
■ Severe and chronic factitious disorder
■ Pseudologia fantastica
– Factitious disorder by proxy
■ A person intentionally produces physical signs or symptoms in another
person under the first person’s care
– Ganser’s syndrome
■ Characterized by the use of approximate answers
52
53. Factitious disorder
■ Subtypes (not in DSM-5 but can still be helpful framework)
– Predominately physical
■ Acute abdominal type
■ Hematological type
■ Neurologic type
■ Dermatologic type
■ Febrile type
■ Endocrine type
■ Cardiac type
– Predominately psychological
53
54. Factitious disorder
■ Methods of inducing factitious illness
– Exaggerations
– Lies
– Tampering with tests to produce positive results
– Manipulations that cause actual physical harm
54
55. Factitious disorder
■ Differential diagnosis
– Must establish the intentional and conscious production of symptoms
■ Direct evidence
■ Excluding other causes
– True physical illness
– Other somatoform disorders
– Malingering
55
56. Factitious disorder
■ Predisposing factors
– True physical disorders in childhood leading to extensive medical treatment
– Employment (present or past) as a medical paraprofessional
– Severe personality disorder
56
58. Factitious disorder
■ Typical hospital admission
– Weekend or late night admission
– Praise then punish and demand behavior while hospitalized
– Anger from treatment team
– Discharge
– Readmission to another hospital
58
59. Factitious disorder
■ Management
– 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
59
60. Malingering
■ Definition
– The intentional production of feigning illness
– Motivated by external incentives
■ Drugs
■ Litigation
■ Financial compensation
■ Avoid work/military service
■ Evade criminal prosecution
60
61. Malingering
■ Clinical features
– Suspect malingering when:
■ Discrepancy between complaints and findings
■ Lack of cooperation with evaluation
■ Obvious gains
■ Concurrent antisocial personality
61
62. Malingering
■ Management
– Identification without placating
– Non-judgmental approach
– Matter-of-fact based on evidence that is available
– Offer support available to manage distress related to current psychosocial
stressors
62
63. Psychological Factors Affecting Other Medical
Conditions
■ A medical symptom or condition is present.
■ Psychological and/or behavioral factors adversely affect the medical
condition in one of the following ways:
– The factors have influenced the course of the medical condition.
– The factors interfere with the treatment of the medical condition.
– The factors constitute health risks for the individual.
– The factors influence the underlying pathophysiology, resulting in symptoms or
necessitating medical attention.
■ The psychological and behavioral factors are not better explained by another
mental disorder.
63
64. Somatic Symptom Disorders
Summary
• Patients with somatic symptoms respond to the presence of physical complaints and
health concerns with excessive and maladaptive thoughts, feelings, and/or behaviors.
• It is not the absence of an identified medical etiology of the physical complaints that is
the focus of the somatic symptom disorders, but rather how they interpret and adapt to
them.
• Conversion Disorder (Functional Neurological Symptom Disorder) differs from the
other somatic symptoms disorders in that a medically unexplained symptom of the
voluntary motor and sensory nervous system remains a key feature of this diagnosis.
• In Illness Anxiety Disorder a patient experiences intense concern about acquiring or
preoccupation with having, an undiagnosed medical illness.
65. Selected References
■ LaFrance WC . Somatoform disorders. Semin Neurol. 2009; 29(3):234-46.
■ Hatcher S, Arroll B. Assessment and management of medically unexplained symptoms. BMJ.
2008;336(7653):1124-8.
■ Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet.
2007;369(9565):946-55.
■ Kirmayer LJ, Groleau D, Looper KJ, Dao MD. Explaining medically unexplained symptoms. Can J
Psychiatry. 2004;49(10):663-72.
■ Wise MG, Ford CV. Factitious disorders. Prim Care. 1999;26(2):315-26.
■ McDermott BE, Feldman MD. Malingering in the medical setting. Psychiatr Clin North Am. 2007;30(4):645-
62.
65
67. Case Presentation - Case I
■ History of Present Illness (Chart)
– 50 year-old female admitted from the neurology clinic with complaints of
bilateral ankle pain, right shoulder pain, and right hip pain.
– She reports the ankle pain started with an injury suffered at work, while the
hip pain and shoulder pain were suffered in a fall.
– A “very thorough” outpatient evaluation has not revealed a clear etiology for
the pain complaints.
– Psychiatry has been asked to evaluate for depression contributing to her
pain, which were felt to be disproportionate to injury.
67
68. Case Presentation - Case I
■ History of Present Illness (Patient)
– Suffered ankle injury in a rather dramatic fashion while at work.
■ Multiple physicians involved
■ Legal action for worker’s compensation is pending
■ She would not allow us to confirm this chain of events
– The shoulder and hip pain were suffered after slipping on ice in front of the hotel in which
she had been staying.
■ Legal action is pending for compensation from this fall.
■ Staying in a hotel after selling her home.
■ Plans to move home to CA
– Moved to WI about a year ago to be close to her in-laws after the death of her husband
in Iraq about one year PTA.
– Denied any depression, psychosis, or anxiety symptoms.
– Denied any family history of psychiatric issues.
68
69. Case Presentation - Case I
■ Past Medical History
– Cholecystectomy
– Breast cysts
– Bilateral ankle injury
■ Using bilateral soft casts and crutches
– Shoulder and hip pain
■ Using arm immobilizer
■ Data available
– All laboratory test – WNL
– MRI of brain – normal
– EMG of lower extremities – normal
– MRI of cervical spine – mild budging
– MRI of shoulder – no injury
– Hip & Ankle films – normal
– Bone scan and QSART of LE - normal
69
70. Case Presentation - Case I
■ Mental status examination
– Middle-aged female sitting up in bed with bilateral soft-casts in place and right arm in
sling.
– Very pleasant as interview began
– Good eye contact.
– Speech was fluent and conversational.
– Mood was described as “OK” and affect appeared rather dramatic, bright and somewhat
inappropriate to the situation.
– Thought process was logical and grossly goal directed, although she did tend to
perseverate on her injuries and pain.
– Thought content was without SI/HI or evidence of psychosis.
– Attention was intact.
70
71. Case Presentation - Case I
■ Initial impression….
■ Initial recommendations….
71
72. Case Presentation - Case I
■ Hospital Course
– The negative results of the work-up begin to return and she
becomes increasing labile and irritable. Demanding a more
aggressive work-up to find out what is wrong.
– Patient continued to complain of 10/10 pain without appearing
subjectively distressed.
– Refuses contact with outside providers due to “pending legal action.”
– The primary team does attempt to address her pain without the use
of opiates.
■ Instead utilizing gabapentin and prn acetaminophen.
72
73. Case Presentation - Case I
■ Did your impression change based on the hospital
course?
■ How about your recommendations?
73
74. Case Presentation - Case II
■ History of Present Illness (Chart)
– 47 year-old male admitted through emergency department with
complaints of generalized weakness, abdominal pain, and
falls.
– Had recently been discharged from hospital with similar
complaints and no etiology found.
– Psychiatry consulted to evaluate for “conversion disorder” as
etiology of the patients complaints.
74
75. Case Presentation - Case II
■ History of Present Illness (Patient)
– Patient denies any significant stressors apart from financial
concerns and current somatic complaints. He further denies
any depressive symptoms except for fatigue and weight loss
(25lbs over 4 months).
– Patient also had complaints of polyuria.
– Describes mood as afraid and frustrated, but not depressed or
anxious.
– He studied psychology in college.
75
76. Case Presentation - Case II
■ Past Medical History
– Seasonal Affective Disorder (last 3 years prior)
– Sinusitis (s/p corrective surgery)
■ Data available
– BMP, CBC, LFTs all normal
– Vitamin B12 304
– HIV, RPR, and Lyme NR
– ESR and CRP all normal
– TSH normal
– ANA negative
– SPEP normal
– Acetylcholinesterase level normal
– LP normal
– Head CT – normal
– EMG - normal
76
77. Case Presentation - Case II
■ Mental Status Examination.
– Alert and orientated. Attention was intact.
– Ill appearing thin male supine in bed.
– Psychomotor retardation noted, but firm handshake. No tremor.
– Speech was fluent and conversational.
– Good eye contact was maintained.
– Mood was described as “frustrated.” Affect appeared euthymic and stable.
– Though process was logical.
– Thought content was without evidence of formal thought disorder. No SI/HI
was present.
– Insight and judgment seemed intact.
77
78. Case Presentation - Case II
■ Initial impression….
■ Initial recommendations….
78
79. Case Presentation - Case II
■ Hospital Course (part 1)
– PT/OT evaluation revealed that he was quite unstable and suffered from
orthostatic hypotension.
– Given complaints of weight loss and abdominal pain a CT of the pelvis and
abdomen was performed and was entirely normal.
– An MRI of the brain was normal, but the MRI of the cervical spine revealed
multilevel of degenerative disk disease. Neurosurgery did not feel this was
responsible and recommended no surgical intervention.
– Of recommended labs the Methylmalonic Acid, Pre-albumin, and HgA1c
were all WNL.
– The cortisol, however, was low.
79
80. Case Presentation - Case II
■ Hospital Course (part 2)
– A cosyntropin stimulation test was performed and found to be abnormal
resulting in the diagnosis of adrenal insufficiency.
– The patient was started on steroid replacement with improvement in
symptoms. He was walking better, less orthostatic, and his strength had
improved markedly.
– He did require the addition of fludrocortisone to hydrocortisone to help
manage some residual orthostatic hypotension.
80
81. Case Presentation - Case II
■ Did your impression change?
■ How about your recommendations?
81
82. Case Presentation - Case III
■ History of Present Illness (Chart)
– The patient is a 46 year-old male with a self-reported 6 month history of progressive
depression along with auditory and visual hallucinations who was admitted to the
hospital for a rule-out of a myocardial infarction after experiencing chest pain at the
psychiatric emergency department.
– The patient presented to psych ED with suicidal ideation (SI) earlier in the day. While at
the psych ED he scratched the dorsum of his wrist in a suicide gesture.
– The patient’s first cardiac enzymes and ECG are WNL. No further complaints of chest
pain.
– Since admission to medical hospital 12 hours ago he has been watched by a 1:1 sitter
without evidence of dangerousness, despite continued SI.
82
83. Case Presentation - Case III
■ History of Present Illness (Patient)
– The patient is from Nebraska and has travelled to Wisconsin to be with a
woman he met at a book signing 5 years ago.
– He has been unemployed since a back surgery in 2000.
– He states he has no contact with his family, due to disagreements.
– While at hospital the patient continues to verbalize SI with plan to cut wrists
or buy a gun and shoot himself if discharged. SI began 2-3 months prior to
presentation.
– He endorses all symptoms of depression and both auditory and visual
hallucinations that tell him to harm himself.
– He denies past psychiatric care or h/o suicide attempts other than multiple
superficial cuts over last couple of months.
83
84. Case Presentation - Case III
■ Past Medical History
– Back pain (chronic)
– S/P laminectomy in 1999 and 2000
– Migraine headaches
84
85. Case Presentation - Case III
■ Mental Status Examination
– Alert with intact attention span.
– Well nourished slightly disheveled male in no acute distress.
– Speech was hesitant when answering questions but quite fluent when he
had a point to make.
– Mood was described as “bad.” Affect appeared euthymic and stable. No
tears or labilty observed.
– Thought process was logical and goal-directed.
– Thought content was with continued SI, but no HI. He reported active A/V
hallucination, however there was no objective evidence of this.
– I/J were judged to be poor.
85
86. Case Presentation - Case III
■ Cognitive Examination
– Short verbal WAIS was 80 but inconsistent.
– FMMSE was 18/30 with grossly inappropriate responses
■ 1/3 objects at 5 minutes with substitution of popsicle with fudgcicle and baseball with football.
■ Sentence “Dog green begin plan.”
■ Spells WORLD forwards and states it is backwards.
– Clock grossly impaired.
86
87. Case Presentation - Case III
■ Cognitive Examination
– General questions
■ How many months in a year?
– 11
■ Can you name the 12 months?
– Able to name 8
■ What is 2+2?
– 5
■ What is 2+3?
– 6
■ What is 10-5?
– 6
■ How many legs does a horse have?
– 5
■ How many doors does a 2 door car have?
– 3
■ Who is buried in Grant’s Tomb?
– Me
87
88. Case Presentation - Case III
■ Initial impression….
■ Initial recommendations….
88
89. Case Presentation - Case III
■ Hospital Course (part 1)
– Patient continued to display inconsistencies in memory and cognition.
– Contacted woman whom he came to stay with.
■ She reports that he has been verbalizing concerns about his memory for the
past couple of months.
■ His visit was a surprise, but not as big as when she was told that he was going
to be staying with her.
■ She was unaware of any psychiatric or substance abuse history by the patient.
– Spoke to the physicians at who saw the patient in the psychiatric ED who
did not feel that the patient was truly suffering from any psychotic
symptoms.
89
90. Case Presentation - Case III
■ Hospital Course (part 2)
– Still with SI and reports of A/V hallucinations.
– Requesting narcotics for back pain.
– Uncooperative with attempts at neuropsychiatric testing.
– Head CT was normal.
– Cardiac stress test was normal.
– No dangerousness during his stay at the medical hospital.
– Discharged back to the Mental Health Complex.
90
91. Case Presentation - Case III
■ Did your impression change?
■ How about your recommendations?
91
Editor's Notes
Richardson RD, Engel CC . Evaluation and management of medically unexplained physical symptoms. Neurologist. 2004 ;10(1):18-30.
Richardson RD, Engel CC . Evaluation and management of medically unexplained physical symptoms. Neurologist. 2004;10(1):18-30.
Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134(9 Pt 2):897-904.
Patients with Somatic Symptom disorder are often convinced that their suffering comes from some type of presumably undetected and untreated physical disease state.
Patients suffering from alexithymia, are unable to articulate their internal feeling states in words. They may, therefore, express their feeling through somatic (physical) complaints.
Sifneos PE. The prevalence of 'alexithymic' characteristics in psychosomatic patients. Psychother Psychosom. 1973;22(2):255-62.
DSM-IV TR Criteria
Multiple recurring physical complaints that begin before age 30
All 4 of the following criteria at some point
4 pain symptoms
History of pain related to at least four different sites or functions.
Head, abdomen, back, joints, extremities, menstruation, during sexual intercourse, or during urination.
2 non-pain GI symptoms
History of at least two GI symptoms other than pain.
Nausea, bloating, vomiting, diarrhea, or food intolerance
1 sexual complaint
Sexual or reproductive symptom other than pain.
Sexual indifference, erectile or ejaculatory dysfunction, irregular menses, or excessive menstruation
1 pseudoneurological complaint
Impaired coordination or balance, paralysis, difficulty swallowing, hallucinations, double vision, blindness, or loss of consciousness.
Not caused by known medical condition
Not intentionally produced
Somatization disorder differs from other somatoform disorders because of the multiplicity of the complaints and the multiple organ systems that are affected
Individuals with somatization disorder are generally found in the general medical sector and rarely seek psychiatric care unless urged to do so.
They will often refuse psychiatric intervention even when recommended secondary to their belief that the symptoms are related to an undiagnosed primary medical condition(s).
Etiologies
Defense mechanisms
Strict psychoanalytic interpretations of symptoms rest on the hypothesis that the symptoms substitute for repressed instinctual impulses.
Individuals use bodily metaphors as an expression of emotional distress.
Genetic & family studies
Somatization disorder tends to run in families and occurs in 10-20% of first-degree females of probands of patients with somatization disorder.
Family and twin studies have linked somatization disorder to antisocial personality disorder. Suggesting that somatization disorder and antisocial personality may have a common etiology.
Behavioral
A behavioral perspective emphasizes that parental teaching, parental example, and ethical mores may teach some children to somatize more than others.
A high percentage of patients with somatization disorder had parents who were physically ill.
Biological
Some preliminary studies indicate that cytokines contribute to some of the nonspecific symptoms of disease, such as anorexia, fatigue, and depression.
The hypothesis that abnormal regulation of the cytokine system may result in some of the symptoms seen in somatoform disorder is under investigation.
Early life experiences
Some patients with somatization disorder come from unstable homes and have been physical abused.
Personality
Alexithymia may be associated with somatization disorder.
Medical conditions
Disorders with transient nonspecific symptoms
In the process of diagnosis, the clinician must consider other medical disorders that are characterized by vague, multiple, and confusing somatic symptoms
These medical disorders include multiple sclerosis, myasthenia gravis, systemic lupus erythematous, AIDS, acute intermittent porphyria, hyperthyroidism, hyperparathyroidism, and chronic systemic infections.
The onset of multiple somatic complaints in patients older than 40 should be presumed to be caused by a nonpsychiatric medical condition until an exhaustive medical workup has been completed.
Psychiatric conditions
Other somatoform disorders
Depression
It is important to determine if the patient has a life-long history of unexplained somatic complaints, or whether the somatic complaints are limited to depressive episodes.
Anxiety
Patients frequently believe that they have been sickly most of their lives.
Patient’s medical histories are often circumstantial, vague, imprecise, inconsistent, and disorganized.
Patients classically describe their complaints in a dramatic, emotional, and exaggerated fashion.
It, however, is difficult to explain these medically unexplained somatic complaints as “merely” a psychiatric illness because
When administered structured diagnostic interviews many patients with MUPS do not have appear to have psychiatric diagnoses.
It is rarely clear which came first - the psychiatric illness or the somatic symptoms. Which is the cause and which is the effect?
The response rate to psychiatric interventions directed against the perceived underlying psychiatric illness (i.e., depression) are often much less than for the expected response rates .
“The most helpful intervention maybe a caring, respectful, long-term relationship not linked to testing, surgery or resolution of symptoms.”- Quill, 1985
Psychiatric consultation is useful only when it is acceptable to the patient
Once somatization disorder has been diagnosed, the treating physician should listen to the somatic complaints as emotional expressions rather than emotional complaints.
A reasonable long-range treatment strategy is to increase the patient’s awareness of the possibility that psychological factors are involved in the symptoms until the patient is willing to see a psychiatrist.
Quill TE. Somatization disorder. One of medicine's blind spots. JAMA. 1985;254(21):3075-9.
Sox HC Jr, Margulies I, Sox CH. Psychologically mediated effects of diagnostic tests. Ann Intern Med. 1981;95(6):680-5.
Howard L, Wessely S, Leese M, et al. Are investigations anxiolytic or anxiogenic? A randomized controlled trial of neuroimaging to provide reassurance in chronic daily headache. J Neurol Neurosurg Psychiatry. 2005;76(11):1558-64.
Psychotherapy
Not responsive to insight orientated psychotherapy
Cognitive-behavioral therapy may be effective
Essentially, patients and clinicians should pinpoint the visceral sensations, the thoughts that were elicited by the discomfort, and the context in which the discomfort occurred.
Psychotherapy, both individual and group, decreases these patients’ health care expenditures by 50%, largely by decreasing their rates of hospitalizations.
In psychotherapy the patients are helped to cope with their symptoms, to express underlying emotions, and to develop alternative strategies for expressing their emotions.
Allen LA, Woolfolk RL, Escobar JI, et al. Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial. Arch Intern Med. 2006;166: 1512-8.
Reassurance is one of the most important modalities clinicians can use.
Kathol, 1997
Question and examine the patient
Assure the patient that a serious illness is not present
Suggest that the symptom will resolve
Tell the patient to return to normal activity
Consider nonspecific treatment
Follow the patient
Kathol RG. Reassurance therapy: what to say to symptomatic patients with benign or non-existent medical disease. Int J Psychiatry Med. 1997;27(2):173-80.
Fink P, Rosendal M,Toft T. Assessment and treatment of functional disorders in general practice: the extended reattribution and management model--an advanced educational program for nonpsychiatric doctors. Psychosomatics. 2002;43(2):93-131.
Knipschild P, Arntz A. Pain patients in a randomized trial did not show a significant effect of a positive consultation. J Clin Epidemiol. 2005;58(7):708-13.
A disturbance in bodily functioning that does not conform to current concepts of the anatomy and physiology of the voluntary nervous system.
It typically occurs in a setting of stress and produces considerable dysfunction.
Functions served by conversion symptoms
The main goals of symptom production are the symbolic resolution of unconscious conflicts and an attempt to keep the conflicting memories out of consciousness.
Imposing punishment on oneself via disabling symptom for a forbidden wish or wrongdoing.
Removing oneself from an overwhelming life-threatening situation.
Psychoanalytic factors
A conversion disorder is caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptoms.
The symptom allows partial expression of the forbidden wish or urge, but disguise it, so the patient can avoid consciously confronting their unacceptable impulses.
Reflexes remain normal: the patients have no fasciculations or muscle atrophy: EMG findings are normal.
Because of the psychological nature of the deficit, the loss of motor function reflects the patient’s perception of neurological function rather than neural innervations.
Anesthesia
Map dermatomes: Sensory loss does not conform to recognized pattern of distribution
Blindness
In conversion disorder blindness, for example, the patients walk around without collisions or self-injury, their pupils react to light, and their cortical evoked potentials are intact.
Ask a patient to touch his index fingers: Even blind patients can do this by proprioception.
Dissociation of function
This phenomenon involves the apparent lack of function of an organ or limb for certain purposes, such as writing, but with no apparent difficulties in performing other tasks or functions with the same organ or limb, such as scratching.
Glove or stocking distribution
Hemianesthesias
Clear sensory loss that stops in the midline and commonly involves an entire side of the body.
“la belle indifference”
The patient’s inappropriate cavalier attitude toward serious symptoms.
It hasas been historically thought to suggest the presence of a conversion disorder, however more recent studies suggest that this is not a very reliable sign of conversion.
Slater ET, Glithero E . A follow-up of patients diagnosed as suffering from "hysteria“. J Psychosom Res. 1965;9(1):9-13.
Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria“. BMJ. 2005;331(7523):989.
Functional Neuroimaging
Abnormalities in functional neuroimaging could be secondary to…
Cause of the disorder
Consequence of the disorder
Compensation for the disorder
Treatment
General/conservative
Reassurance
The first step involves reassuring the patient that the symptoms are not the result of medical condition, but are secondary to an underlying psychological conflict.
Addressing the stressors that may have lead to the onset of symptoms.
General steps:
Protective environment
Reassurance that a full medical workup has been done
No permanent damage has been found
Full recovery is expected
Physical and occupation therapy
The initial symptoms of most patients resolve in a few days or less than a month
Psychotherapies
Amytal interview
If the symptom can be resolved by suggestion, hypnosis, or parenteral Amytal, they are probably the result of a conversion disorder
Symptoms or deficits are usually of short duration, and approximately 95% of acute cases remit spontaneously, usually within 2 weeks in hospitalized patients.
If symptoms are have been present for 6 months or longer, the prognosis for symptom resolution is less than 50% and diminishes further the longer the disorder is present.
The physician does not have to judge the pain to be “inappropriate” or “in excess of what would be expected.”
The phenomenological and diagnostic focus is on the importance of psychological factors and the degree or impairment caused by the pain.
Purely physical pain
Purely physical pain can be difficult to distinguish from purely psychogenic pain, especially because the two are not mutually exclusive.
Physical pain fluctuates in intensity and is highly sensitive to emotional, cognitive, attentional, and situational influences.
Pain that does not vary and is insensitive to these factors is likely to be psychogenic.
Pain that does not wax and wane and is not even temporarily relieved by distraction or analgesics, clinicians can suspect an important psychogenic component.
Depression
Major depression is present in about 25-50% of patients with pain disorder.
Dysthymic disorder or depressive symptoms are reported in 60-100% of the patients.
Other somatoform disorders
Pain is, by definition, not a symptom in conversion disorder.
Malingering
A patient’s pain may be posttraumatic, neuropathic, neurological, iatrogenic, or musculoskeletal; to meet a diagnosis of pain disorder, however, the disorder must have a psychological factor judged to be significantly involved in the pain symptoms and their ramifications
Goal is likely an improvement in functioning rather than a complete relief of pain
Because it may not be possible to reduce the pain, the treatment approach must address rehabilitation.
Physicians must stress an understanding that the patient’s experiences of pain are real.
Clinicians should discuss the issue of psychological factors early in treatment and should frankly tell patients that such factors are important in the cause and consequences of both physical and psychological pain.
Pharmacotherapy
Antidepressants, such as TCAs and SSRIs, are the most effective pharmacological agents.
The term hypochondriasis is derived from the term hypochondrium which means below the ribs, and reflects the abdominal complaints of many of these patients.
Medical students: 3%
Usually in the first two years.
Usually transient
The belief, however, cannot have the intensity of a delusion (more appropriately diagnosed as a delusional disorder).
The belief cannot be restricted to distress about the appearance (more appropriately diagnosed as body dysmorphic disorder).
Similar to somatization disorder, hypochondriasis is characterized by the presence of unexplained symptoms and sensations. However, the patient with hypochondriasis takes these symptoms one step further by leaping to a catastrophic cognitive misinterpretation of the significance of these symptoms, thereby convincing themselves that they have a physical disease.
Chronic with waxing and waning of symptoms
When the course is chronic, hypochondriasis may appear similar to lifetime OCD or a personality disorder.
When the course is intermittent or off new onset, the physician should search for predisposing stressful life events as the cause.
Etiologies
Hypochondriasis results from patients’ unrealistic or inaccurate interpretations of physical symptoms or sensations, even though no medical cause can be found.
Psychodynamic model
Aggressive and hostile wishes towards others are transferred (repression and displacement) into physical complaints.
The pain becomes a means of punishment of past wrongdoing.
Cognitive-behavioral model
Hypochondriasis stems from faulty perceptions and unrealistic threat appraisals in which individuals misinterpret harmless bodily symptoms as having serious health implications.
“Better safe than sorry” strategy.
The patient’s inability to separate harmless aches and pains from more serious health threats results in either hypervigilance to bodily sensations, reassurance seeking, or avoidance behaviors.
The essence of CBT treatment for hypochondriasis involves the identification and correction of this flawed belief system.
Physiologic model
Persons with hypochondriasis augment and amplify their somatic sensations.
They have low thresholds for, and low tolerance of, physical discomfort.
Treatment
General aspects
Establishment of trust
Frequent, regularly scheduled physical examinations help to reassure patients that their physicians are not abandoning them and that their complaints are being taken seriously.
History taking
Identification of stressors
The clinician should attempt to identify any environmental, social, or biologic factors that could be maintaining the illness-related fears.
Education
Cognitive-behavioral therapy
CBT therapists help their patients understand that an organic medical disorder is not the only reasonable explanation for highly distressing physical symptoms and that distorted patterns of cognition have problematic emotional and behavioral consequences.
Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA. 2004;291:1464-70.
Supportive therapy
Supportive therapy is nonspecific, but it generally includes reassurance, education, and life stressor management.
Pharmacotherapy
Serotonergic medications (TCAs and SSRIs) appear to benefit 70-80% of patients.
Patients with factitious disorder fake illness
Intentionally exaggerates or induces signs and symptoms of illness.
Clinicians can assess whether a symptom is intentional both by direct evidence and by excluding other causes.
FD is diagnosed in persons who intentionally exaggerate or induce signs and symptoms of physical or mental illness or who pretend to be physically or mentally ill when they are not.
Motivation is to assume the sick role
Other incentives for the illness inducing behavior are absent
In severe cases of FD the intentional and conscious production of symptoms are relatively easy to diagnose. In lesser cases this determination maybe much more challenging.
In cases characterized by medical complaints for which there are no physical indicators (e.g., chronic pain or weakness), it can be very difficult to confidently diagnose FD.
Many patients suffered childhood abuse resulting in frequent hospitalizations.
The inpatient stay may have been regarded as an escape from a traumatic home situation.
The patient may have found a series of caretakers to be loving and caring. In contrast to the patients’ abusive or neglectful families of origin.
Patients usually perceive one or both parents as rejecting and unable to form close relationships.
The usual history reveals that the patient perceives one or both parents as rejecting figures who are unable to form close relationships.
The “facsimile” of genuine illness, therefore, is used to recreate the desired positive parent-child bond through the sick role.
Self-enhancement model
FD is often a means of increasing or protecting self-esteem.
Allows patients to blame potential failures on their illness.
Boost of self-esteem through their association with prestigious physicians and medical facilities.
Gives patients a way to project themselves as heroic and brave or medically knowledgeable and sophisticated.
The diagnosis of a rare medical condition may allow a FD patient to feel unique.
Munchausen syndrome
2/3 of patients are male
Peregrination
When patients’ deception is uncovered, the patients play out their role at other hospitals in the same city or another, thus repeating the pattern.
Impostership
Many patients assume the identity of a prestigious person. Men, for example, report being war heroes and attribute their surgical scars to wounds received in battle or in other dramatic and dangerous exploits. Similar they may say they have ties to accomplished or renowned figures.
Pseudologia fantastica
Telling grand lies about their educational or military credentials, their past exploits, their social or political connections, and so forth.
Limited factual material is mixed with extensive and colorful fantasies.
The listener’s interest pleases the patient and thus reinforces the symptom.
Munchausen’s by proxy
In this disorder, a person intentionally produces physical signs or symptoms in another person who is under the first person’s care.
Most commonly perpetrated by mothers against infants or young children
Rare or unrecognized, it accounts for less than 0.04%, or 1,1000 of 3 million cases of child abuse reported in the US each year.
Ganser’s Syndrome
Characterized by the use of approximate answers.
Patients with this disorder respond to simple questions with astonishingly incorrect answers. (i.e., 1 + 2 = 4)
Predominately physical
The essential feature of patients with the disorder is their ability to present to physical symptoms so well as to gain admission to, and stay in, a hospital.
The most common clinical problems feigned or produced are infection, impaired wound healing, hypoglycemia, anemia, bleeding, rashes, neurologic symptoms, vomiting, diarrhea, pain or fever of undetermined origin.
It is likely that the FD patient’s choice of disease reflects a careful balance between the desire to effectively deceive medical staff and to command their avid attention and concern.
Predominately psychological
Cases of feigned psychological signs and symptoms are reported much less commonly than those of physical signs and symptoms.
Differential diagnosis
Must establish the intentional and conscious production of symptoms
Careful verification of all the facts presented by the patient about previous hospitalizations and medical care is essential.
True physical illness
Somatoform disorders
A factitious disorder is differentiated from somatization disorder by the voluntary production of factitious symptoms, the extreme course of multiple hospitalizations, and the seeming willingness of patients with factitious disorder to undergo an extraordinary number of invasive and often dangerous procedures.
Malingering
The distinction between these two conditions depends on the underlying motivation. In malingering, there are clear external incentives. In contrast in factitious disorder the motivation is presumed to be a psychological need to assume to sick role.
These patients usually stop producing their signs and symptoms when they are no longer considered profitable or when the risk becomes to great.
The admission of a patient with factitious disorder often follows a familiar pattern. These patients often present over the weekend or afterhours when they envision the less experienced clinicians are on call. They initially will heap praise upon the treatment them (“I know you will be the one to figure out what is wrong with me.”). As test after test come back negative and treatment after treatment are found to be ineffective, frustration begins to build. The treatment team begins to suspect that the patient may be inducing their illness and a sense of countertransference anger often arises. Around this same time, the patient starts to sense that the gig may be up and feels threatened and starts acting out and becoming hostile. The patient often leaves AMA only to present at another local hospital to start this grand adventure once again.
No specific treatment shown effective
Prognosis is poor.
It is a paradox that patients with the disorder simulate serious illness and seek and submit to unnecessary treatment for a disorder that they do not have “naturally,” while they deny to themselves and others their true illness and thus avoid possible treatment for it.
Direct confrontation rarely worked to change the patient’s behavior.
Clearly explain that the treatment teams expectation for recovery and inform the patient that if the condition does not improve, they will be forced to conclude that the problem is likely factitious in origin. DOUBLE BIND
Early identification
Perhaps the single most important factor in successful management is a physician’s early recognition of the disorder.
Beware of negative countertransference
Can be very challenging.
In essence, staff members are forced to abandon a basic element of their relationship with patients: accepting the truthfulness of their statements.
One must remain aware that even though the patient’s presenting illness is factitious, the patient is ill!