Prof P M Joubert Department of Psychiatry 2016 The Somatic Symptom and Related Disorders of the DSM-5

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4 Outline of Presentation I.What is meant by somatic symptom disorders? II.What falls under the somatic symptom disorders? III.5 Case studies for you to diagnose. IV.The individual somatic symptom disorders. V.5 Case studies revisited. VI.Management.

5 I.What is meant by the somatic symptom and related disorders?  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.

6 II.What falls under somatic symptom and related disorders?  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.

7 III.5 Case Studies

8 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 work- up no medical explanation for the sudden loss of vision could be found.  Diagnosis: ?

9 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: ?

10 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: ?

11 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: ?

12 Case 5  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: ?

13 IV.The Individual Somatic Symptom Disorders

14 Somatic symptom disorder  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.

15 Somatic symptom disorder  Specifiers:  With predominant pain.  Persistent (continuous, disabling, severe symptoms).  Severity: mild, moderate, severe.

16 Illness anxiety disorder  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.

17 Illness anxiety disorder  Specifiers:  Care-seeking type.  Care avoidant type.

18 Conversion disorder  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

20 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.

21 Factitious disorder  Factitious disorder imposed on self.  Deception about physical or psychological symptoms or signs, having the person presenting himself as ill, impaired or injured, without any clear external rewards.

22 Factitious disorder  Factitious disorder imposed on another.  Deception about physical or psychological symptoms or signs, having the person presenting another person as ill, impaired or injured, without any clear external rewards.

23 Other specified somatic symptoms and related disorder  Includes:  Pseudocyesis.  Brief somatic symptoms disorder.  Brief illness anxiety disorder.

24 Unspecified somatic symptoms and related disorder  Can’t place it in any of the specified categories.

25 V.5 Case Studies Revisited

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 work- up no medical explanation for the sudden loss of vision could be found.  Diagnosis: ?

27 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 work- up no medical explanation for the sudden loss of vision could be found.  Diagnosis: conversion disorder with special symptoms categories.

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: ?

29 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.

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: ?

31 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.

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: ?

33 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.

34 Case 5  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: ?

35 Case 5  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.

36 VI.Management

37 Management  Challenging.  Complicated.  Varies from one condition to the other.  May or may not involve a multidisciplinary team.

38 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).