Dying to get a diagnosis
A 23-year-old woman presents to the emergency department to evaluate recurrent tingling in her right upper extremity. The patient reports, “I woke up with tingling in my right arm again today, and I think I might be having a stroke.” The patient has no past medical history and does not take any medications daily. The patient is currently enrolled in graduate school, smokes Marijuana occasionally, and consumes Alcohol socially. This is the 8th emergency department visit with similar complaints over the past year. The patient has had multiple negative workups, including CTs and MR imaging of the brain and evaluation by multiple neurologists.
Vital signs are within normal limits. The neurologic evaluation demonstrates 5/5 strength in the upper and lower extremities bilaterally. The patient states sensation to light touch is 50% on the right upper extremity when compared to 100% on the left
upper extremity. Which of the following is the most likely diagnosis?
a. somatic symptom disorder
b. conversion disorder
c. Munchausen syndrome by proxy
d. Malingering
e. Vulnerable child syndrome
Answer Somatic symptom disorder
Somatic symptom disorder is defined by at least one unexplained physical symptom that has been present for ≥ 6 months. Common physical symptoms include vague neurologic complaints, back pain, gastrointestinal symptoms, or pelvic pain. Patients with somatic symptom disorder are frequently anxious about their health, self-diagnosed, and mistrust the physician's diagnosis, often demanding repeat evaluation via imaging, blood work, or specialty consultation.
What are the 3 main assessment tools most likely to be utilized
GAD-7 anxiety screening tool
PHQ-9 patient health questionnaire
HAM-D Hamilton Depression rating scale
Name some of the factors you should consider when referring a patient to a mental health professional
Location, insurance coverage, specific needs of the patient, expertise of mental health professionals
Describe 1 theory explaining the pathophysiology of somatic symptom disorder
Cause of symptoms is unknown.
1. Originally thought to be a result of too much psychological stress
2. caused by patients perceiving bodily sensations in an unusual way
3. patients may describe feelings in physical terms rather than mental or emotional. Trauma/stress may alter the pt's physical sensation
True or False: Patients with somatization disorder should only meet with their PCP when they are experiencing symptoms.
False: They should initially meet on a regular schedule regardless of symptoms to establish a sense of trust.
A 17-year-old girl presents to her primary care physician to evaluate right leg weakness for two weeks. The patient states, “I can't lift my right leg, and it feels numb too. I haven’t been able to walk or go to school because of my symptoms.” The patient's parent states, “I don’t know what’s wrong. I know school has been hard this year with her applying to college, but all of this just came out of the blue.” The patient is otherwise healthy and neither uses illicit substances nor consumes alcohol. Vital signs are within normal limits. The patient has 2+ symmetric reflexes in the bilateral lower extremities on physical examination. Plantar reflex testing results in flexionof the big toe bilaterally. While the patient lies supine, the physician places a hand under the right heel; when asked to lift the left leg against resistance, the patient exerts downward Pressure with the right heel. Further history gathering is most likely to reveal which of the following?
a. family hx of demyelinating disease
b. recent heavy lifting
c. recent emotional or physical trauma
d. recent "bulls-eye" rash
e. recent episode of diarrhea
Recent emotional or physical trauma
This otherwise healthy patient presents for evaluation of spontaneous right lower extremity weakness. Physical examination demonstrates a positive Hoover sign, a technique used to differentiate between the actual and functional weakness of the lower extremities. When asked to raise the unaffected leg, patients with functional weakness will exert downward pressure on the affected heel. Together, these findings are suspicious for conversion disorder, often triggered by recent emotional or physical trauma.
What is the GAD used to screen for (four answers)?
GAD, panic disorder, social anxiety, PTSD
Name two things that EIR interoperability positively influenced in the study that Priyanka found.
Reduced patient safety events, medication safety, reduced costs
Somatoform disorders are characterized by which of the following?
a) Self-induced disease states or faked symptoms to garner attention
b) Physical symptoms coupled with extreme focus on emotional state
c) Severe physical symptoms that cannot be explained by any organic or physical pathology
d) Self-inflicted injuries
C
Describe the concept of "doctor shopping."
Patients may frequent different hospitals or urgent care centers looking for answers and additional opinions.
A patient reports that every morning after waking up and before breakfast his stomach makes this “bizarre” sound described as “growling.” He also has fatigue. His highest level of education is middle school; he is low socioeconomic status, and he recently moved to the area. What is his most likely diagnosis?
a. conversion disorder
b. factitious disorder
c. illness anxiety disorder
d. malingering
e. somatic symptom disorder
Answer E
The correct answer is somatic symptom disorder (E). Somatic symptom disorder is more common in patients with low levels of education, low socioeconomic status, and a recent major life change or event. It may involve misconstruing normal bodily functions as reasons for extreme concern and anxiety. Conversion disorder (A) involves unexplained neurologic symptoms such as loss of vision or ability to speak. Factitious disorder (B) consists of an individual fabricating illness to obtain attention from health care professionals by playing the sick role. Illness anxiety disorder (C) revolves around the excessive concern of acquiring or having acquired a serious illness. Malingering (D) is defined by falsifying symptoms for secondary gain such as food or shelter.
How is the total score of the GAD-7 anxiety screening tool interpreted (give range)
___= minimal symptoms
___= mild symptoms
___= moderate symptoms
___=severe symptoms
Interpretation of total score: Total Score Anxiety Severity 1-4 minimal symptoms 5-9 mild symptoms 10-14 moderate symptoms 15-21 severe symptoms
Local practitioners, referral networks, professional associations, insurance networks, community mental health centers, online directories, consultant services
Name 2 bodily symptoms our patient experienced that could be explained by somatic symptom disorder
1. pain --> pt had chronic pelvic pain that began in her 20s
2. Neurologic problems --> pt was dizzy, fatigued, and "passed out"
3. GI complaints --> pelvic pain that started after her hysterectomy and complaints of constipation.
4. sexual symptoms (our patient did not have)
What should you do if your patient is reluctant to accept their diagnosis of somatization disorder?
Obtain authorization to speak to family members and have family meetings/therapy to better understand the patient
Physician may consult a psychiatrist to discuss the case (without using PHI or breaking HIPAA) to get additional advice on how to help the patient
A 34-year-old man presents to the emergency department for evaluation of
difficulty sleeping. The patient states, “Doctor, I can't sleep. There has to be something wrong. I think I need another CT scan of my brain.” The patient is otherwise healthy and does not take any medications daily. The patient's mother died from glioblastoma multiforme three years ago. When questioned further, the patient has been reading about brain tumors for multiple hours per day and has lost interest in activities he used to enjoy. The patient has started taking nutritional supplements and exercising excessively in an attempt to prevent cancer. This is the patient's 4th emergency department visit with similar presentations in the past six months. Vital signs are within normal limits, and neurologic examination is non-focal. Which of the following is the most likely diagnosis?
a. Factitious disorder
b.Somatic symptom disorder
c. Illness anxiety disorder
d. Conversion disorder
e. Major depressive disorder
Answer: illness anxiety disorder
This patient presents with excessive worry regarding the development of malignancy and anxiety about health without experiencing actual somatic symptoms, which is most consistent with the diagnosis of illness anxiety disorder.
Evaluate the performance of the first group of antidepressants
Describe the collaborative care model.
PCPs provide psychiatric care by consulting with psychiatrists and a care manager. Can include therapy and medications without needing to see a specialist.
A 45-year-old man is brought to the emergency department because of chest
pain for the past 3 hours. The patient has been seen several times in the last year for similar symptoms, however, each time cardiac evaluation is normal. History reveals no cardiac risk factors. The patient says he barely leaves his house and had to quit his job because he fears his symptoms of chest pain will begin and he will not be able to reach a hospital. After thorough evaluation, all tests are negative. The patient becomes frustrated and storms out of the hospital demanding a second opinion. Which of the following is the most likely diagnosis?
a. adjustment disorder
b. conversion disorder
c. somatic symptom disorder
d. panic disorder
e. post-traumatic stress syndrome
C. somatic symptom disorder
Somatic symptom disorder is a DSM-V diagnosis characterized by excessive preoccupation with minor bodily symptoms. Patients often self diagnose themselves and do not believe the physician's negative work-up. Preoccupation with or fear of their symptomatology can often inhibit a patients ability to perform important activities, such as work, school activities, or family and social responsibilities. The preoccupation must be present for at least six months.
Treatment consists of regular follow-up visits and offering psychotherapy. The patient should not be told that these symptoms are imaginary. This diagnosis was previously known as hypochondria, but in the DSM-V that diagnosis is not possible. A similar DSM-V diagnosis to somatic symptom disorder is illness anxiety disorder which is characterized by intense anxiety about an undiagnosed condition.
Explain the treatment goals for someone with somatization disorder.
Learn to cope with the physical symptoms to reduce the anxiety surrounding them.
Establish a trusting relationship with the physician.
A 42-year-old man presents to the emergency department with sudden left-arm weakness. He states that he left the house after an argument with his wife and was unable to open the car door because his arm “stopped working.” Over the past few months, he has had many arguments with his wife but has not had a similar episode. He has no history of major medical illness. Physical examination is normal, including 2+ deep tendon reflexes and intact sensation, except for 0/5 strength in his left arm. A CT scan of the head is normal. Which of the following is the most likely cause of the patient’s sudden arm weakness?
a. conversion disorder
b. factitious disorder
c. illness anxiety disorder
d. malingering
e. somatic symptom disorder
Answer: conversion disorder
Conversion disorder manifests with dysfunction of voluntary motor or sensory systems without a physiologic cause, often following an acute stressor. Motor dysfunction (eg, paralysis) is typically coupled with normal deep tendon reflexes and normal sensation, with patients sometimes being indifferent toward the symptoms (“la belle indifference”).
Patients with illness anxiety disorder have a preoccupation with having or acquiring a serious, undiagnosed illness for ≥6 months, but somatic symptoms themselves are mild or nonexistent.
Somatic symptom disorder requires one or more somatic symptoms that cause a patient significant distress or psychosocial impairment for ≥6 months.
Patients with factitious disorder seek primary gain in the form of the assumption of the sick role (eg, attention, caretaking).
Malingering patients consciously fake or exaggerate for secondary gain, such as money, housing, or avoidance of responsibilities.
The PHQ-9 is based on the diagnostic criteria for major depressive disorder. Name 5 of these criteria.
S - sleep disturbance
I - Interest
G - Guilt/ worthlessness
E - Energy
C - Concentration problems
A - Appetite
P - Psychomotor agitation or retardation
S - Suicidal ideation
What does the C.R.A.P. acronym stand for in the context of evaluating a research study?
Currency, reliability, authority, purpose/POV
A 21-year-old woman comes to the emergency department because of a sudden loss of sight and inability to walk. She complains of pain when seeing bright light and prefers to wear sunglasses. On physical examination, she is not able to track the fingers and has no peripheral vision, but does display a response when touching her eyelashes. A magnetic resonance imaging study is not able to determine a diagnosis. She is told that the etiology of her sudden blindness or difficulty to walk is unknown. She replies indifferently, stating that maybe she'll get better one day. She requests breakfast and and appears unusually apathetic. She appears to be unable to put her feelings into words. Which of the following is the term that describes this condition?
a. dyslexia
b. dysthymia
c. pure alexia
d. alexithymia
e. aphasia
Answer: D Alexithymia
Alexithymia describes a patient that cannot put their feelings into words. This often affects those with somatization disorder or conversion disorder.
Alexithymia is a personality construct characterized by the inability to identify and describe emotions in the self. It involves dysfunction in emotional awareness, social attachment, and interpersonal relating. Many individuals with alexithymia have difficulty distinguishing and appreciating the emotions of others, which can to lead to ineffective emotional responding. These patients are at an increased risk for binge eating, substance abuse, perverse sexual behavior, or anorexia nervosa. This disorder is known to be co-morbid with a number of other psychiatric conditions, such as somatic symptom disorder or conversion disorder. It has been found that the degree of alexithymia is influenced by age, but not by gender. It is unclear what causes this disorder.
Other:
a. dyslexia --> trouble reading
b. dysthymia --> mood disorder consisting of the same cognitive and physical problems as in depression, with less severe, but longer-lasting symptoms.
c. pure alexia --> suffer from reading problems while other language-related skills intact
e. inability to comprehend and formulate language due to dysfunction in specific brain regions
A 25-year-old woman comes to the urgent care clinic because of she felt a sudden onset of left lower extremity paralysis that lasted for a few minutes when she was at home. The patient is in moderate distress and states that this morning her partner of five years abruptly ended their relationship and will not answer her calls. She reports feeling depressed and confused as to why this happened. She denies thoughts of harming herself or others at this time. Neurologic and musculoskeletal examination of the patient is normal. Laboratory studies were also within normal limits. Which of the following options is the best first line of treatment for this patient?
A. Admission to the hospital
B. Fluoxetine
C. No treatment necessary
D. Psychotherapy
D. Psychotherapy