Somatic Symptom and Related Disorder Amirul Ashraf and Ahmad Alif Azfar 5th year group B3

Seminar Outline Introduction Classification Disorder by Disorder Treatment

-Somatic Symptoms: “somatic (from the Greek σωματικός) means 'of the body'—relating to the body” -Common feature: The prominence of somatic symptoms with significant distress and impairment -It’s what you’re going to encounter more often in medical rather than psychiatric settings! -Often not mutually exclusive (e.g. Mood disorders with somatic symptoms) 50 % of the patient have other mental disorders ..eg : MDD, AD

Somatic Symptom disorder and others VS Factitious Disorder and Malingering

Classification Somatic Symptom Disorder Illness anxiety Disorder Conversion Disorder (Functional neurological symptom disorder) Factitious Disorder Other specified somatic symptom and related disorder Non-specified somatic symptom and related disorder -Malingering

Multiple, often non-specific with many organ systems involvement . Many visits, hospitalization, lab or surgeries on the same chronic complaint with no findings.

Somatic Symptom Disorder They are not feigning the symptoms. It is unconscious in order to gain something (primary gain or secondary gain) Gain = Motivator

-Patients can express distress in relation to other things in life or express it exclusively to symptoms. -In children a single complaint is often present which is often abdominal pain, fatigue, headache or nausea *75% of Hypochondriasis is being diagnosed as somatic symptom disorder after criteria change

DDx: (Think Anxiety/OCD and related disorders/Other disorders of the same category) Other medical conditions (diagnose with both or only as associated somatic symptoms if criterion B is not met) Panic Disorder (Episodic) GAD (Not only health. Worry about everything) Illness anxiety (Minimal somatic symptoms) Conversion disorder ( Focus in somatic is on distress vs loss of function) Delusional disorder (Intensity of belief) 7. OCD 8. Body Dysmorphic Disorder

Management Approach Presenting the Diagnosis (Summarize and explain) Refer to a psychiatrist for diagnosing co-morbidities Set a single primary care physician to take care of the patient’s complaints. His approach should be focused on limiting investigations but not neglecting carrying them out if need arises (Risk of associated real medical illness) Pharmacotherapy often not yielding

Somatic Symptom Disorder Counseling (Skim and Scan) Psychoeducation can be helpful by letting the patient know that physical symptoms may be exacerbated by anxiety or other emotional problems. However, be careful because patients are likely to resist suggestions that their condition is due to emotional rather than physical problems. The primary care physician should inform the patient that the symptoms do not appear to be due to a life-threatening, disabling, medical condition and should schedule regular visits for reassessment and reinforcement of the lacking severity of ongoing symptoms. The patient also may be told that some patients with similar symptoms have had spontaneous improvement, implying that spontaneous improvement may occur. However, the physician should accept the patient's physical symptoms and not pursue a goal of symptom resolution. Indeed, regular, noninvasive, medical assessment reduces anxiety and limits health care–seeking behavior; this may be facilitated by regularly scheduled visits with the patient's primary care physician. Encourage patients to remain active and limit the effect of target symptoms on the quality of life and daily functioning. Family members should not become preoccupied with the patients physical symptoms or medical care. Family members should direct the patient to report symptoms to their primary care physician.

The DSM-IV defines hypochondriasis according to the following criteria:[4] A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder). D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration of the disturbance is at least 6 months. F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode,Separation Anxiety, or another Somatoform Disorder.

DDx: -Other medical conditions (can be mutually exclusive. To tell them apart think criterion C) -Somatic Symptom disorder (Criterion B) -Anxiety Disorder GAD (?) Panic disorder (Episodic) -OCD (Fear of future disease versus fear of having current disease) -Major depression (Not made if concern is only there during depressive episodes) -Psychotic disorders (often more bizzare, e.g. rotting organs)

Treatment Pharmacotherapy isn’t the answer Physicians should attempt to answer questions and reduce the patient's fear of a specific illness. Group psychotherapy may provide social support and reduce anxiety. Cognitive therapy strategies may help by focusing on distorted disease-related cognitions*

Conversion disorder Have at least one neurological symptoms (eg : blindness, paralysis, parasthesia) Usually preceded / exarcebated by psychological stressor Patient usually calm and unconcerned when describing their symptoms

Conversion Disorder

- F:M (2-3:1) Onset at any age ( adolescence / early adulthood ) High incidence with comorbid schizophrenia, major depression or anxiety disorder

Treatment & Prognosis Most patients recover spontaneously  Insight-oriented psychotherapy, hypnosis, relaxation therapy Symptoms may be brief / last for several weeks / longer 25% will have future episodes

Factitious Disorder Intentionally produce medical / psychological symptoms in order to assume the role of a sick patient Primary gain is a prominent feature Commonly feigned symptoms : Psychiatric : hallucinations, depression Medical : fever, abdominal pain, seizures, skin lesions, hematuria

-Exaggeration, fabrication, stimulation and induction (Mechanisms of falsifying illness) -DECEPTION IS THE RULE Manipulate lab tests (Adding blood to urine) Cause harm to themselves (Injecting fecal material) Faking seizures/blackouts Falsify records Fake a loved one’s death (Spouse that doesn’t exist) Ingest substances to fake results (e.g. Insulin)

Management Establish the presence of any comorbidities Treat comorbidities accordingly (possible Hospitalization) Limited benefit of pharmacotherapy or particular psychotherapy techniques Attempting to establish a strong relationship and try to help the willing patients is the idea approach Never ignore assessing the factitious symptoms! You never know when it’s real!

Malingering Feigning of physical / psychological symptoms in order to achieve personal gain ( avoiding the police, receiving room and board, obtaining narcotics, receiving money) Usually present with multiple vague symptoms that do not conform a known medical history Often have long medical history and multiply hospitalization Generally uncooperative and refuse to accept good prognosis Symptoms improve once their desired objective is obtained

THANK YOU 