Transcript Somatic symptom disorder

The Somatic Symptom and
Related Disorders of the DSM-5
Prof P M Joubert
Department of Psychiatry
2016
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Outline of Presentation
I.
II.
III.
IV.
V.
VI.
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What is meant by somatic symptom disorders?
What falls under the somatic symptom disorders?
5 Case studies for you to diagnose.
The individual somatic symptom disorders.
5 Case studies revisited.
Management.
I. What is meant by the somatic
symptom and related disorders?
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All of them have the following in common:
 Noticeable bodily symptoms.
 Noticeable bodily signs.
 Undesirable thoughts, feelings, and behaviours about the body
symptoms or signs.
 Suffer distress about the body symptoms or signs
 Impaired functioning due to the body symptoms or signs.
II. What falls under somatic symptom and related
disorders?
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Somatic symptom disorder.
Illness anxiety disorder.
Conversion disorder.
Psychological factors affecting other medical conditions.
Factitious disorder.
Other specified somatic symptom and related disorder.
Unspecified somatic symptom and related disorder.
III. 5 Case Studies
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Case 1
 30-year old Jane Do suddenly lost her ability to see. She went
for medical work-up from general practitioners to specialists.
In the mean time she started wearing large dark glasses and
acquired a neat, foldable white cane. After an extensive workup no medical explanation for the sudden loss of vision could
be found.
 Diagnosis: ?
8
Case 2
 35-year old John Do’s father died of a heart attack 1 year ago.
Since then John fears getting a heart attack despite feeling well.
Yet he can’t help worrying about it nearly constantly. He checks
his pulse rate frequently. He is easily alarmed if the pulse rate
goes over a 80 or falls below 65, because, “72 is a normal pulse
rate”. He goes from one medical practitioner to the other,
including specialists, to seek reassurance that he is well. He can
by reassured briefly, because his CVS checks out normal, but the
reassurance does not last long before the worrying starts again.
 Diagnosis: ?
9
Case 3
 35-year old John Do’s father died of a heart attack 1 year ago.
Since then he gets episodes of tightness around the chest
accompanied by a feeling of having difficulty to breathe. Now he
can’t help worrying about the tightness around the chest nearly
constantly. He checks his pulse rate frequently. He is easily
alarmed if the pulse rate goes over a 80 or falls below 65,
because “72 is a normal pulse rate”. He goes from one medical
practitioner, including specialists, to the other to find reassurance
that he is well. He is temporarily reassured when his CVS checks
out normal, but the reassurance does not last long before the
worrying starts again.
 Diagnosis: ?
10
Case 4
 15-year old Jane Do’s suffers from insulin dependent diabetes
mellitus. She has been thoroughly informed on how to use
insulin and what her diet should be. Furthermore, she is an
intelligent girl who understand all of this. Nonetheless, she
frequently attends teenage parties where she recklessly
overindulges in carbohydrate containing foods and drinks,
which, on more than one occasion, ended in an emergency
admission because of a hyperglycaemic, ketoacidotic coma.
 Diagnosis: ?
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Case 5
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15-year old Jane Do’s suffers from insulin dependent diabetes mellitus.
She has been thoroughly informed on how to use insulin and what her
diet should be. Furthermore, she is an intelligent girl who understand all
of this. Nonetheless, at times she secretly stops her insulin for no clear
external gain like missing a school examination, and takes in too much
carbohydrate containing foods and drinks. This results in
hyperglycaemic, ketoacidotic comas that necessitate emergency
treatment. Because this behaviour is secretive, her doctors wonder what
they are doing wrong regarding her treatment. The patient herself seem
very forgiving, tells them that she knows they are doing their best, and
seems to enjoys the attention of doctors and nurses.
Diagnosis: ?
IV. The Individual Somatic
Symptom Disorders
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Somatic symptom disorder
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Distressing or disruptive somatic symptom(s).
Excessive thoughts, feelings, behaviours about the symptoms or
related health worries as per (at least one) of:
 Persistent, excessive thoughts about symptoms’ seriousness.
 Much anxiety about symptoms or health (persistent).
 Excessive time and energy spent on these symptoms or health
concerns.
More than 6 months of being symptomatic.
Somatic symptom disorder
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Specifiers:
 With predominant pain.
 Persistent (continuous, disabling, severe symptoms).
 Severity: mild, moderate, severe.
Illness anxiety disorder
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Preoccupied with having or getting serious illness.
If there is a physical condition, or risk for it, the preoccupation is
clearly excessive.
Very concerned about their health.
Excessive health related behaviours or maladaptive avoidance.
No/mild somatic symptoms.
Duration 6 months.
Illness anxiety disorder
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Specifiers:
 Care-seeking type.
 Care avoidant type.
Conversion disorder
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There are changes in sensory and voluntary motor functions that are
incompatible with recognized neurological or medical conditions.
Not better explained by another mental disorder or medical disorder.
Significant distress or impairment in functioning.
Conversion disorder
With weakness or paralysis.
With abnormal movements.
With swallowing symptoms.
With speech symptoms.
With attacks or seizures.
With anaesthesia or sensory loss.
With special symptom categories.
With mixed symptoms.
Voluntary motor
Sensory
Both
Psychological factors affecting other
medical conditions
 A psychological factor adversely affects a medical condition
by increasing a known additional health risk.
 It adversely affects the underlying pathophysiology, course, or
adherence to treatment.
 But, the psychological factor is not better explained by
another mental disorder.
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Factitious disorder
 Factitious disorder imposed on self.
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Deception about physical or psychological symptoms or signs,
having the person presenting himself as ill, impaired or injured,
without any clear external rewards.
Factitious disorder
 Factitious disorder imposed on another.
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Deception about physical or psychological symptoms or signs,
having the person presenting another person as ill, impaired or
injured, without any clear external rewards.
Other specified somatic symptoms
and related disorder
 Includes:
 Pseudocyesis.
 Brief somatic symptoms disorder.
 Brief illness anxiety disorder.
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Unspecified somatic symptoms and
related disorder
 Can’t place it in any of the specified categories.
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V.
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5 Case Studies Revisited
Case 1
 30-year old Jane Do suddenly lost her ability to see. She went
for medical work-up from general practitioners to specialists.
In the mean time she started wearing large dark glasses and
acquired a neat, foldable white cane. After an extensive workup no medical explanation for the sudden loss of vision could
be found.
 Diagnosis: ?
26
Case 1
 30-year old Jane Do suddenly lost her ability to see. She went
for medical work-up from general practitioners to specialists.
In the mean time she started wearing large dark glasses and
acquired a neat, foldable white cane. After an extensive workup no medical explanation for the sudden loss of vision could
be found.
 Diagnosis: conversion disorder with special symptoms
categories.
27
Case 2
 35-year old John Do’s father died of a heart attack 1 year ago.
Ever since John fears getting a heart attack despite feeling well
otherwise. He can’t help worrying about it nearly constantly. He
checks his pulse rate frequently. He is easily alarmed if the pulse
rate goes over a 80 or falls below 65, because “72 is a normal
pulse rate”. He goes from one medical practitioner, including
specialists, to the other to find reassurance that he is well. He is
temporarily reassured when his CVS checks out normal, but the
reassurance does not last long before the worrying starts again.
 Diagnosis: ?
28
Case 2
 35-year old John Do’s father died of a heart attack 1 year ago.
Ever since John fears getting a heart attack despite feeling well
otherwise. He can’t help worrying about it nearly constantly. He
checks his pulse rate frequently. He is easily alarmed if the pulse
rate goes over a 80 or falls below 65, because “72 is a normal
pulse rate”. He goes from one medical practitioner, including
specialists, to the other to find reassurance that he is well. He is
temporarily reassured when his CVS checks out normal, but the
reassurance does not last long before the worrying starts again.
 Diagnosis: Illness anxiety disorder, care-seeking type.
29
Case 3
 35-year old John Do’s father died of a heart attack 1 year ago.
Since then he gets episodes of tightness around the chest
accompanied by a feeling of having difficulty to breath. Now he
can’t help worrying about it nearly constantly. He checks his
pulse rate frequently. He is easily alarmed if the pulse rate goes
over a 80 or falls below 65, because “72 is a normal pulse rate”.
He goes from one medical practitioner, including specialists, to
the other to find reassurance that he is well. He is temporarily
reassured when his CVS checks out normal, but the reassurance
does not last long before the worrying starts again.
 Diagnosis: ?
30
Case 3
 35-year old John Do’s father died of a heart attack 1 year ago.
Since then he gets episodes of tightness around the chest
accompanied by a feeling of having difficulty to breath. Now he
can’t help worrying about it nearly constantly. He checks his
pulse rate frequently. He is easily alarmed if the pulse rate goes
over a 80 or falls below 65, because “72 is a normal pulse rate”.
He goes from one medical practitioner, including specialists, to
the other to find reassurance that he is well. He is temporarily
reassured when his CVS checks out normal, but the reassurance
does not last long before the worrying starts again.
 Diagnosis: Somatic symptom disorder.
31
Case 4
 15-year old Jane Do’s suffers from insulin dependent diabetes
mellitus. She has been thoroughly informed on how to use
insulin and what her diet should be. Furthermore, she is an
intelligent girl who understand all of this. Nonetheless, she
frequently attends teenage parties where she recklessly
overindulges in carbohydrate containing foods and drinks,
which, on more than one occasion, ended in an emergency
admission because of a hyperglycaemic, ketoacidotic coma.
 Diagnosis: ?
32
Case 4
 15-year old Jane Do’s suffers from insulin dependent diabetes
mellitus. She has been thoroughly informed on how to use
insulin and what her diet should be. Furthermore, she is an
intelligent girl who understand all of this. Nonetheless, she
frequently attends teenage parties where she recklessly
overindulges in carbohydrate containing foods and drinks,
which, on more than one occasion, ended in an emergency
admission because of a hyperglycaemic, ketoacidotic coma.
 Diagnosis: Psychological factors affecting diabetes mellitus.
33
Case 5


34
15-year old Jane Do’s suffers from insulin dependent diabetes mellitus.
She has been thoroughly informed on how to use insulin and what her
diet should be. Furthermore, she is an intelligent girl who understand all
of this. Nonetheless, at times she secretly stops her insulin for no clear
external gain like missing a test, and takes in too much carbohydrate
containing foods and drinks. This results in hyperglycaemic, ketoacidotic
comas that necessitate emergency treatment. Because this behaviour is
secretive, her doctors wonder what they are doing wrong regarding her
treatment. The patient herself seem very forgiving, tells them that she
knows they are doing their best, and seems to enjoys the attention of
doctors and nurses.
Diagnosis: ?
Case 5


35
15-year old Jane Do’s suffers from insulin dependent diabetes mellitus.
She has been thoroughly informed on how to use insulin and what her
diet should be. Furthermore, she is an intelligent girl who understand all
of this. Nonetheless, at times she secretly stops her insulin for no clear
external gain like missing a test, and takes in too much carbohydrate
containing foods and drinks. This results in hyperglycaemic, ketoacidotic
comas that necessitate emergency treatment. Because this behaviour is
secretive, her doctors wonder what they are doing wrong regarding her
treatment. The patient herself seem very forgiving, tells them that she
knows they are doing their best, and seems to enjoys the attention of
doctors and nurses.
Diagnosis: Factitious disorder imposed on self.
VI. Management
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Management
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Challenging.
Complicated.
Varies from one condition to the other.
May or may not involve a multidisciplinary team.
Management
 Always involves a pivotal health professional that:
 Has infinite patience and good interpersonal skills.
 Has established good rapport with the patient.
 Acts as an anchor person for the MDT.
 Follows-up the patient frequently.
 Always involves avoiding habit forming drugs where possible.
 Always involves search for comorbid mental illness that can
be treated (e.g., major depressive disorder).
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