SOMATIZATION & somatIC - PowerPoint Presentation

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SOMATIZATION & somatIC symptom dIsorders

Fatih

Kokdere

Yeditepe

University

School

of

Medicine

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INTRODUCTIONSomatization is a syndrome of physical symptoms that are distressing and may not be fully explained by a known medical condition.The symptoms may be caused or exacerbated by anxiety, depression, and interpersonal conflicts; and it is common for somatization, depression, and anxiety to all occur together.Somatization

can be conscious or unconscious

.

It increases use of medical services

,

leads to frustration in both the patient and the clinician

.

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TERMINOLOGY AND DSM-5Somatization is an overarching term that encompasses many different illnesses and terms including “somatoform disorders”, which is a group of disorders that are recognized in the ICD-10 and were previously described in

the

DSM-IV-TR.

DSM-5 does not use the term

somatization

, and has eliminated the category of diagnoses called somatoform disorders.

For patients with prominent somatic symptoms that cause distress and impair psychosocial functioning, DSM-5 has replaced the category of somatoform disorders with a category called

somatic symptom and related disorders

.

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EPIDEMIOLOGYSomatization is common in the general population. More than 50 percent of patients presenting to outpatient medical clinics with a physical complaint do not have a medical condition.Somatization, defined in one study as four or more unexplained physical symptoms in men and six or more unexplained physical symptoms in women, occurred in 17 percent of patients in primary care settings and 4 percent of the general US populationA systematic review of 21 European studies found the median 12-month prevalence rate for any somatoform disorder was 6 percent of the general population

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RISK FACTORSFemale sexFewer years of educationMinority ethnic statusLow socioeconomic statusChildhood sexual abuse and recent exposure to physical or sexual violence

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CLINICAL PRESANTATIONThe essential feature of somatization is a history of physical symptoms that the patient attributes to a nonpsychiatric disease.Pain symptoms, including headache, back pain, dysuria, joint pain, diffuse pain, and extremity painGastrointestinal symptoms, including nausea, vomiting, abdominal pain, bloating, gas, and diarrheaCardiopulmonary symptoms, including chest pain, dizziness, shortness of breath, and palpitations 

Neurologic

symptoms

,

including

fainting

,

pseudoseizures

,

amnesia

,

muscle

weakness

,

dysphagia

,

double

or

blurred

vision

,

difficulty

walking

,

difficulty

urinating

,

deafness

,

and

hoarseness

or

aphonia

Reproductive organ symptoms, including

dyspareunia

,

dysmenorrhea

, and burning in sex organs

Reproductive organ symptoms, including

dyspareunia

,

dysmenorrhea

, and burning in sex organs

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Coexisting psychIatRIC IlLnessesSomatization is strongly associated with anxiety and depression.  In a study of 10,000 primary care patients, those with somatization were six times more likely to manifest anxiety or depression compared to those without

somatization

(30 versus 5 percent)

.

In addition to depression and anxiety,

somatization

is often associated with personality disorders. In a study that assessed 94 patients with

somatization

disorder with structured interviews, at least one personality disorder was found in 61 percent . The most common were avoidance, paranoia, self-defeating, and obsessive-compulsive.

It is unclear whether there is an association between

somatization

and substance use disorder

.

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SOMATIC SYMPTOM AND RELated dIsorders In DSM-5, the category of somatic symptom and related disorders encompasses disorders that are marked by prominent somatic symptoms as well as substantial distress and/or psychosocial impairmentSomatic

symptom

disorder

Illness

anxiety

disorder

Conversion

disorder

(

functional

neurological

symptom

disorder

)

Psychological

factors

affecting

other

medical

conditions

Factitious

disorder

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SOMATIC SYMPTOM DISORDER A DSM-5 diagnosis of somatic symptom disorder requires each of the following criteria;One or more somatic symptoms that cause distress or psychosocial impairmentExcessive thoughts, feelings, or behaviors associated with the somatic symptoms, as demonstrated by one or more of the following: - Persistent thoughts about the seriousness of the symptoms - Persistent, severe anxiety about the symptoms or one’s general health

-

The time and energy devoted to the symptoms or health concerns is

excessive

Although the specific somatic symptom may change, the disorder is persistent (usually more than six months)

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SOMATIC SYMPTOM DISORDER

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SOMATIC SYMPTOM DISORDER

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ILlNESS ANXIETY DISORDER A DSM-5 diagnosis of illness anxiety disorder requires each of the following criteriaPreoccupation with having or acquiring a serious, undiagnosed illnessSomatic symptoms are mild or nonexistent at mostSubstantial anxiety about health and a low threshold for becoming alarmed about one’s healthEither excessive behaviors related to health (eg

, repeatedly checking oneself for signs of illness), or maladaptive avoidance of situations or activities (

eg

, exercise) that are thought to represent health threats

The illness preoccupation is present for at least six months

The illness preoccupation is not better explained by other mental disorders (

eg

, somatic symptom disorder, generalized anxiety disorder, or somatic type of delusional disorder)

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CONVERSION DISORDERConversion disorder (functional neurologic symptom disorder) is characterized by

neurologic

symptoms

(

eg

,

weakness

,

abnormal

movements

,

or

nonepileptic

seizures

)

that

are

inconsistent

with

a

neurologic

disease

,

cause

distress

 

and

/

or

 

psychosocial

impairment

.

T

he diagnosis of conversion disorder (functional neurologic symptom disorder) should be made after the neurologist has established positive clinical findings that are incompatible with disease or are inconsistent across different parts of the examination 

In

DSM-5,

the diagnosis of conversion disorder does not require that clinicians identify psychological factors associated with the conversion symptoms

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CONVERSION DISORDER

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CONVERSION DISORDER

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CONVERSION DISORDER

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FACTITIOUS DISORDER(munchausen syndrome)Patient consciously creates physical and

/

or

psychological

symptoms

in

order

to

assume

sick

role

and

to

get

medical

attention

.

Characterized

by

a

history

of

multiple

hospital

admissions

and

willingness

to

undergo

invazive

procedures

.

Two

types

:

Imposed

on self

and

Imposed

on

another

(

child

,

older

adult

..)

 

I

n contrast to malingering, in which the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty.

Health

care

workers

!

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FACTITIOUS DISORDER(munchausen syndrome) A DSM-5 diagnosis of factitious disorder on self requires each of the following criteriaFalsification 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

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Munchausen syndrome by proxyFactitious disorder imposed on

another

.

Illness

in a

child

or

elderly

patient

is

caused

or

fabricated

by

the

caregiver

.

Motivation

is

to

assume

a

sick

role

by

proxy

.

It

is a form of

child

/

elder

abuse

.

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When to suspect ?Inconsistencies in the history, examination, and laboratory testsRefusal to grant access to information from external sources such as prior medical records as well as family and friendsTests and procedures, including those that are risky, are eagerly accepted

Lengthy and extensive clinical evaluation (

eg

, large number of consultations and tests) that is negative

Opposition

to

consulting

psychiatry

Use of multiple healthcare facilities

Course of illness is unusual

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FACTITIOUS DISORDER(munchausen syndrome)

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MalingeringPatient consciously fakes, profoundly exaggerates or claims to have

a

disorder

in

order

to

attain

a

spesific

secondary

gain

(

avoiding

work

…)

Characterized

by

poor

compliance

with

treatment

or

follow

-

up

diagnostic

tests

and

ceasing

of

complaints

after

gain

(vs

factitious

disorder

)

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Malingering

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Psychological factors affecting other medical conditionsPsychological factors affecting other medical conditions (PFAOMC) is a disorder that is diagnosed when a general medical condition is adversely affected by psychological or behavioral factors; the factors may precipitate or exacerbate the medical condition, interfere with treatment, or contribute to morbidity and mortality. In addition, the factors are not part of another mental disorder (eg, unipolar major depression).

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DIAGNOSTIC CRITERIA The diagnosis of PFAOMC requires each of the following criteriaA general medical symptom or disorder is presentPsychological or behavioral factors negatively affect the medical condition in one or more of the following ways, such that the factors:-Pose additional health risks for the patient-Aggravate the underlying pathophysiology

of a medical condition and precipitate or exacerbate symptoms

-Affect the course of the medical condition, as manifested by a close temporal relationship between the factors and the onset or exacerbation of the medical condition

-Disrupt treatment of the general medical condition  

Other mental disorders do not better explain the psychological or behavioral factors

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Psychological factors affecting other medical conditionsA previously healthy 45 year old male reports chest pain that only occurs when he loses his temper and yells at his assistant, wife, and children. A Holter monitor shows signs of ischemia and premature ventricular contractions while yelling, and a stress test and cardiac catheterization confirm a diagnosis of coronary artery disease. The temporal link between anger and angina supports a diagnosis of PFAOMC.

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Key features

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treATMENTPharmacotherapy and psychotherapy are each beneficial, and there is no evidence to indicate one is better than the other.Patients with somatization often have comorbid depressive and anxiety disorders. Somatization frequently resolves when these psychiatric syndromes are appropriately treated.Cognitive Behavioral

Therapy

-

the evidence supporting CBT is stronger than it is for any other psychotherapy.

Tell patients that their symptoms are taken seriously

Avoid describing symptoms as entirely psychogenic (“all in your head”)

Avoid further referrals and laboratory tests unless there is a clear indication of a general medical disorder

.

Schedule regular visits

.

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treATMENT - pharmacotherapySSRI (NNT:3) : Initial treatment with fluoxetine 20 mg per day. TCAs

: Side

effects

?

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ReferencesSomatization: Epidemiology, pathogenesis, clinical features, medical evaluation,

and

diagnosis

. [online]

Available

at: https://www.uptodate.com/contents/somatization-epidemiology-pathogenesis-clinical-features-medical-evaluation-and-diagnosis [

Accessed

12

Apr

. 2017].

Conversion disorder in adults: Clinical features, assessment, and

comorbidity

. [online] Available at: https://www.uptodate.com/contents/conversion-disorder-in-adults-clinical-features-assessment-and-comorbidity?source=search_result&search=conversion+disorder&selectedTitle=1~44 [Accessed 12 Apr. 2017].

Psychological factors affecting other medical conditions: Clinical features, assessment, and diagnosis

. [online] Available at: https://www.uptodate.com/contents/psychological-factors-affecting-other-medical-conditions-clinical-features-assessment-and-diagnosis?source=search_result&search=psychologic+factors+affecting&selectedTitle=1~150 [Accessed 12 Apr. 2017].

Somatization

: Treatment and prognosis

. [online] Available at: https://www.uptodate.com/contents/somatization-treatment-and-prognosis?source=search_result&search=somatization+treatment&selectedTitle=1~150 [Accessed 12 Apr. 2017]