SOMATIC SYMPTOM AND RELATED DISORDERS.pptx

Somatic symptoms

1. SOMATIC SYMPTOM AND RELATED DISORDERS PRESENTED TO :BMS 5.1 SPECIALS PSYCHIATRY CLASS PRESENTERS: NASASIRA CALEB KAZINI GADAFFI HILLARY ANATOSI SUPERVISOR :DR. RAISSA

2. LEARNING OBJECTIVES By the end of this presentation, we should be able to: Define somatic symptom and related disorders (SSRDs). Classify the different types of SSRDs (DSM-5 criteria). Understand the etiology and risk factors. Recognize clinical features and diagnostic challenges. Discuss management approaches.

3. INTRODUCTION Somatic symptom and related disorders are characterized by physical symptoms causing significant distress or impairment , with excessive thoughts, feelings, or behaviors related to the symptoms. Symptoms may or may not be explained by another medical condition. Previously called “somatoform disorders” (DSM-IV) which included; ,, -Somatization Disorder -Undifferentiated somatoform disorder -Conversion disorder -Pain disorder -Hypochondriasis -Body dysmorphic disorder -Somatoform disorder not otherwise specified

4. MAJOR CHANGES DSM IV (SOMATOFORM DISORDERS) DSM-5 (SSRDs) KEY CHANGES Somatization disorder Replaced by somatic symptom disorder SSD Replaced with SSD which focuses on distress/ impairment rather than symptom count hypochondriasis Replaced by illness anxiety disorder if minimal sx or SSD if significant sxs No longer requires “fear of disease” to be delusional, split based on somatic sx Pain disorder Absorbed into SSD Classified under SSD if it causes significant distress/disruption Undifferentiated somatoform disorder Merged into SSD conversion disorder Renamed fx neurologic sx disorder Psychological factors affecting medical condition Retained but expanded Factitious disorder Split into 2;on self and on another Medically unexplained sxs removed Body dysmorphic disorder BDD Moved to OCD

5. Reasons for Changes observed DSM 5 DSM-IV term somatoform disorders was confusing Nonpsychiatric physicians found the DSM-IV Somatoform diagnoses difficult to understand DSM IV required symptoms to be ‘medically unexplained’ To reduce stigma and improve diagnostic accuracy Overlap and poor reliability in DSM IV diagnoses Hypochondriasis was too narrow and stigmatizing Conversion disorder needed modernization Factitious disorder clarification

6. DSM-5 classification of SSRDs

7. SOMATIC SYMPTOM DISORDER SSD SSD involves 1 or more distressing physical symptoms accompanied by excessive thoughts, feelings or behaviors related to the symptoms. Patients believe that they have some severe yet undetected disease, and evidence to the contrary does not persuade them otherwise. The focus is on the disproportionate psychological response rather than the medical severity of the symptoms.

8. EPIDEMIOLOGY Prevalence: ~5-7% in the general population. More common in women F:M ~5:1 Often begins in early adulthood.

9. ETIOLOGY AND RISK FACTORS Biological : Genetic predisposition, heightened pain sensitivity. Psychological : history of trauma, anxiety, or depression Sociocultural : Reinforcement of illness behavior (e.g. family attention for symptoms)

10. CLINICAL FEATURES Physical symptoms like chronic pain, fatigue, GI distress Excessive worry about symptoms like believing mild back pain is cancer Frequent doctor visits or, conversely, avoidance of medical care due to fear.

11. DSM-5 DIAGNOSTIC CRITERIA One or more 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 one of the following: 1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms. 2. Persistently high level of anxiety about health or symptoms. 3. Excessive time and energy devoted to these symptoms or health concerns. C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

12. Specify if : With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain. Specify if: Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). Specify current severity: Mild: Only one of the symptoms specified in Criterion B is fulfilled. Moderate : Two or more of the symptoms specified in Criterion B are fulfilled. Severe : Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

13. DIFFERENTIAL DIAGNOSIS Medical conditions like multiple sclerosis, lupus Illness anxiety disorder (no or mild symptoms, focus is on fear of illness) Major depressive disorder (if somatic symptoms occur only during depressive episodes)

14. TREATMENT Psychotherapy: CBT (challenge catastrophic thinking, reduce health anxiety) Medication: SSRIs e.g. (fluoxetine) for comorbid anxiety/depression Collaborative care: single primary care provider to avoid unnecessary tests.

15. Course and prognosis Chronic, but symptoms may improve with treatment Poor prognosis if comorbid personality disorder or poor social support

16. Illness Anxiety Disorder (Hypochondriasis) Illness Anxiety Disorder Patients with illness anxiety disorder, like those with somatic symptom disorder, believe they have a serious but undiagnosed disease despite evidence to the contrary. They may maintain a belief that they have a particular disease or, as time progresses, they may transfer their belief to another disease. Their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians

17. EPIDEMIOLOGY Prevalence: ~1-5% Equally common in men and women Onset usually in early adulthood

18. Etiology Cognitive factors: misinterpretation of bodily sensations Behavioral factors: reinforcement from reassurance-seeking. Family history of anxiety disorders

19. Clinical features persistent fear of illness e.g. believing a headache is a brain tumor Excessive health related behaviors e.g. frequent doctor visits, googling symptoms Avoidance of medical settings due to fear of bad news

20. DSM-5 DIAGNOSTIC CRITERIA A. Preoccupation with having or acquiring a serious illness. B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals). E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time. F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

21. Specify whether: Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used. Care-avoidant type: Medical care is rarely used.

22. DIFFERENTIAL DIAGNOSIS Somatic symptom disorder (focus is on symptoms, not disease fear) OCD (obsessive health related rituals) Generalized anxiety disorder (worry extends beyond health)

23. Treatment CBT (exposure therapy to reduce checking behaviors) SSRI e.g. sertraline for comorbid anxiety Limit reassurance- seeking e.g. restricting doctor visits

24. Course and prognosis Chronic but manageable with therapy. May worsen during stress or after exposure to illness related media

25. Conversion Disorder (Functional Neurologic Symptom Disorder) Persons with conversion disorder (also called functional neurologic symptom disorder) present with what appears to be a neurologic condition. The symptoms may be motor or sensory but are incompatible with known neurologic conditions. Often the illness is preceded by conflicts or other stressors and may seem to be associated with apparent psychological factors. Individuals with conversion disorder do not intentionally produce these symptoms or deficits. Conversion motor symptoms mimic syndromes such as paralysis, ataxia, dysphagia, or seizure disorder (nonepileptic seizures [NESs]), and the sensory symptoms mimic neurologic deficits such as blindness, deafness, or anesthesia. • There can also be disturbances of consciousness (e.g., amnesia, fainting spells). Epi

26. Epidemiology Two to three times more common in women than men. Onset at any age, but more often in adolescence or early adulthood. High incidence of comorbid neurological, depressive, or anxiety disorders.

27. Etiology Psychological stress; e.g. trauma, abuse Neurobiological factors; abnormal brain connectivity in sensorimotor regions

28. Clinical features Motor symptoms; weakness, paralysis, tremors. Sensory symptoms; numbness, blindness, deafness Non-epileptic seizures (pseudo-seizures) La belle indifference ( lack of concern about symptoms, thought not always present

29. DSM DIAGNOSTIC CRITERIA A. One or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C. The symptom or deficit is not better explained by another medical or mental disorder. D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Coding note: The ICD-10-CM code depends on the symptom type (see below).

30. Specify symptom type: F44.4 With weakness or paralysis F44.4 With abnormal movement (e.g., tremor, dystonia, myoclonus, gait disorder) F44.4 With swallowing symptoms F44.4 With speech symptom (e.g., dysphonia, slurred speech) F44.5 With attacks or seizures F44.6 With anesthesia or sensory loss (e.g., visual, olfactory, or hearing disturbance) F44.6 With special sensory symptom F44.7 With mixed symptoms Specify if : Acute episode: Symptoms present for less than 6 months. Persistent : Symptoms occurring for 6 months or more. Specify if: With psychological stressor (specify stressor) Without psychological stressor

31. DIFFERENTIAL DIAGNOSIS Neurological disorders e.g. multiple sclerosis, epilepsy Malingering/factitious disorder; intentional feiggning

32. Treatment and Prognosis The primary treatment is education about the illness. • Cognitive behavioral therapy (CBT), with or without physical therapy, can be used if education alone is not effective. While patients often spontaneously recover, the prognosis is poor: symptoms may persist, recur, or worsen in 40–66% of patients.

33. Psychological Factors Affecting Other Medical Conditions Patients with this disorder have physical disorders caused by or adversely affected by emotional or psychological factors like stress, denial, anxiety which negatively impact the course, treatment or recovery of a diagnosed medical condition. A medical condition must always be present to make the diagnosis. Common clinical examples include denial and refusal of treatment for an acute condition (such as myocardial infarct or abdominal emergencies) by individuals with certain personality styles (e.g., domineering or controlling), the exacerbation of asthma or irritable bowel attacks by anxiety, and the manipulation of insulin by an individual with diabetes.

34. Epidemiology Common in chronic illnesses like DM, hypertension No precise prevalence data but often seen in stress exacerbated conditions like asthma, IBS

35. CLINICAL FEATURES Worsening of medical illness due to psychological factors eg a diabetic patient skipping insulin due to depression Denial od illness like hypertensive patient refusing mediation because they ‘feel fine’ Anxiety induced symptoms exacerbated e.g. panic attacks triggering asthma

36. DSM 5 DIAGNOSTIC CRITERIA A. A medical symptom or condition (other than a mental disorder) is present. B. Psychological or behavioral factors adversely affect the medical condition in one of the following ways: 1. The factors have influenced the course of the medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition. 2. The factors interfere with the treatment of the medical condition (e.g., poor adherence). 3. The factors constitute additional well-established health risks for the individual. 4. The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention. C. The psychological and behavioral factors in Criterion B are not better explained by another mental disorder (e.g., panic disorder, major depressive disorder, posttraumatic stress disorder).

37. Specify current severity: Mild: Increases medical risk (e.g., inconsistent adherence with antihypertension treatment). Moderate: Aggravates underlying medical condition (e.g., anxiety aggravating asthma). Severe: Results in medical hospitalization or emergency room visit. Extreme: Results in severe, life-threatening risk (e.g., ignoring heart attack symptoms)

38. DIFFERENTIAL DIAGNOSIS Adjustment disorder (if distress is due to adjusting illness) Somatic symptom disorder (if focus is on symptoms rather than medical management)

39. Treatment and Prognosis The primary treatment is education about the illness. Cognitive behavioral therapy (CBT), with or without physical therapy, can be used if education alone is not effective. While patients often spontaneously recover, the prognosis is poor: symptoms may persist, recur, or worsen in 40–66% of patients.

40. FACTITIOUS DISORDERS Patients with factitious disorder feign, misrepresent, simulate, cause, induce, or aggravate illness to receive medical attention, regardless of whether or not they are ill. Thus, they may inflict painful, deforming, or even life threatening injuries on themselves, their children, or other dependents. The primary motivation is not the avoidance of duties, financial gain, or anything concrete. The motivation is simply to receive medical care and to partake in the medical system.

41. Continuation Factitious disorders can lead to significant morbidity or even mortality. Therefore, even the patients falsify their presenting complaints, health professionals must take the medical and psychiatric needs of these patients seriously, as their self-induced symptoms can result in significant harm or even death. Historically this disorder was called “Munchausen syndrome, ” a reference to the Baron Munchausen, legendary for his outrageously exaggerated stories of his military career

42. subtypes Factitious disorder imposed on self e.g. self-injecting bacteria to induce infection. Factitious disorder imposed on another (formerly Munchausen by proxy) e.g. a parent poisoning a child to get medical attention.

43. epidemiology May be at least 1% of hospitalized patients More common in women (when imposed on self) and caregivers (when imposed on another) Often linked to child abuse history. Higher incidence in hospital and health care workers (who have learned how to feign symptoms). Associated with personality disorders.

44. Diagnostic Criteria DSM 5 Factitious Disorder Imposed on Self Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents himself or herself to others as ill, impaired, or injured. The deceptive behavior is evident even in the absence of obvious external rewards. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder. Specify: Single episode Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

45. Diagnostic Criteria DSM 5 Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy) A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception. B. The individual presents another individual (victim) to others as ill, impaired, or injured. C. The deceptive behavior is evident even in the absence of obvious external rewards. D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder. Note: The perpetrator, not the victim, receives this diagnosis. Specify: Single episode Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

46. Treatment and Prognosis Collect collateral information from medical providers and family. Collaborate with primary care physician and treatment team to avoid unnecessary procedures. Patients may require confrontation in a nonthreatening manner; however, patients who are confronted may leave against medical advice and seek hospitalization elsewhere. Repeated and long-term hospitalizations are common

47. MÜNCHAUSEN SYNDROME Factitious disorder with predominantly physical Sx Similar clinical features and management Münchausen syndrome by Proxy Intentionally produce symptoms in individual under care of patient • Usually vulnerable individuals like children

48. Other Specified and Unspecified Somatic Symptom and Related Disorders Patients with other specified somatic symptom and related disorders present with somatic symptoms that do not meet the threshold for another disorder. For example, they may present with symptoms consistent with illness anxiety disorder, except that the symptoms do not meet the duration criterion; in this case, the diagnosis would be brief illness anxiety disorder. When there is not enough information to make a specific diagnosis, then clinicians should use the unspecified somatic symptom and related disorder diagnosis.

49. Other Specified Somatic Symptom and Related Disorder DSM 5 This category applies to presentations in which symptoms characteristic of a somatic symptom and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class. Examples of presentations that can be specified using the “other specified” designation include the following: Brief somatic symptom disorder: Duration of symptoms is less than 6 months. Brief illness anxiety disorder: Duration of symptoms is less than 6 months. Illness anxiety disorder without excessive health-related behaviors or maladaptive avoidance: Criterion D for illness anxiety disorder is not met. Pseudocyesis: A false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy.

50. Unspecified Somatic Symptom and Related Disorder DSM-5 CRITERIA This category applies to presentations in which symptoms characteristic of a somatic symptom and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class. The unspecified somatic symptom and related disorder category should not be used unless there are decidedly unusual situations where there is insufficient information to make a more specific diagnosis.

51. MALINGERING A 37-year-old patient claims that he has frequent episodes of “seizures, ” starts on medications, and joins an epilepsy support group. It becomes known that he is doing this in order to collect social security disability money. Diagnosis? Malingering. In contrast, in factitious disorder, patients look for some kind of unconscious emotional gain by playing the “sick role, ” such as sympathy from the physician. The fundamental difference between malingering and factitious disorder is in the intention of the patient; in malingering, the motivation is external, whereas in factitious disorder, the motivation is internal. lingering involves the intentional reporting of physical or psychological symptoms in order to achieve persona

52. Presentation Patients usually present with multiple vague complaints that do not conform to a known medical condition. They often have a long medical history with many hospital stay They are generally uncooperative and refuse to accept a good prognosis even after extensive medical evaluation. Their symptoms improve once their desired objective is obtained

53. Epidemiology Not uncommon in hospitalized patients Significantly more common in men than women. Management Work with the patient to manage their underlying distress, if possible. Gentle confrontation may be necessary; however, patients who are confronted may leave the hospital AMA(against medical advice) and seek treatment elsewhere

54. Review of Distinguishing Feat Somatic symptom disorders: Patients believe they are ill and do not intentionally produce or feign symptoms. Factitious disorder: Patients intentionally produce symptoms of a psychological or physical illness because of a desire to assume the sick role, not for external rewards. Malingering: Patients intentionally produce or feign symptoms for external rewards

55. References DSM V TR pg. 349 KAPLAN AND SADOCKS SYNOPSIS OF PSYCHIATRY pg. 319 KAPLAN & SADOCK’S SYNOPSIS OF PSYCHIATRY TWELFTH EDITION