Potpourri
What are the two most common psychiatric comorbidities of somatic symptom disorders?
Depression & anxiety
What is another name for conversion disorder?
Functional neurological symptom disorder
TRUE or FALSE:
Measurable significant physical symptoms are actually present in illness anxiety disorder.
FALSE.
In illness anxiety disorder, the focus is on the fear of getting sick rather than actually feeling or being sick. If sick symptoms are actually present, they are usually very mild or benign. If sick symptoms are significant, then somatic symptom disorder is a better fit for diagnosis.
What is remarkable about the physical exam in patients with reported functional neurological symptom disorder (conversion disorder)?
The reported symptoms and complaints are inconsistent with known neuroanatomical and physiological pathways.
In a patient with factitious disorder, when confronting them, will they admit to intentionally producing their symptoms?
Nope. And they usually get pretty offended at the suggestion.
Anxiety exacerbating chest pain or manipulating of thyroid medication to lose weight are prime examples of which somatic symptom disorder?
Psychological factors affecting medical illness
What is the updated term for "pseudoseizure"?
Psychogenic non-epileptic seizure (PNES)
Patients with illness anxiety disorder don't respond well to reassurance and don't feel validated in their concerns. As a result, what main behaviors can they exhibit?
Care-seeking subtype - doctor shopping
Care-avoidant subtype - avoidance of medical care
Other than PNES, what are some other manifestations of conversion disorder?
"Hysterical blindness"
Paresthesias
Abdominal pain
Mutism
Globus hystericus
Speech disturbances
Paralysis
What is the motivational drive or reward sought out by patients with factitious disorder?
Primary gain - "the sick role"
No drive for external reward/secondary gain (money, shelter, disability benefits, etc.)
What medication may be helpful in patients with somatic symptom disorder with predominant pain as well as depression?
Duloxetine (Cymbalta), as well as other SNRIs
Falsification of physical or psychological signs or symptoms, or induction of injury or disease with identified deception with a sick or injured presentation is the hallmark of which disorder?
Factitious disorder
In severe forms, Munchausen disorder
Factitious disorder imposed on another (Munchausen by proxy)
What are the risk factors for illness anxiety disorder?
Major life stress
History of child abuse
History of serious illness early in life
When a patient's neurological symptoms and affect are not congruent with the severity of symptoms in conversion disorder, what is that classically called?
"La belle indifference"
In this movie clip (and what movie is it?), what disorder does the mother of this girl likely exhibit?
The Sixth Sense
Factitious disorder imposed on another (Munchausen by proxy)
Is this video an example of PRIMARY gain (achieving the sick role) or SECONDARY gain (for external reward)?
SECONDARY gain (external reward), i.e. to get out of school - "how can anyone be expected to handle school on a day like this?"
What is this movie, and why did I pick it for this super, fun, amazing learning activity?
Joe vs. the Volcano
Joe likely has illness anxiety disorder in the context of work/social stress and existential crisis. Or conversion disorder in the form of globus hystericus.
TRUE or FALSE - Illness anxiety is more common in women than in men.
FALSE.
Although somatic symptom disorder and conversion disorder are more common in women, the male to female ratio for illness anxiety disorder is 1:1.
Statistics based on hypochondriasis in the DSMIV show prevalence of 1-10%.
TRUE or FALSE - A diagnosis or suspicion of conversion disorder rules out true epilepsy.
There is a high comorbidity of EEG-defined epilepsy and psychogenic non-epileptic seizure activity found in conversion disorder.
A 38 year-old divorced nurse with a history of depression, currently on disability for chronic low back pain, presents to the hospital with a third episode of syncope in the last month. She reports just before she passes out feeling very lightheaded, confused, dizzy, and shaky. Cardiac work up was negative, including a TILT test and orthostatics. All other labs remained normal. You look at her medical record and realize this the is the third time in the last 2 months the patient has presented with the same symptomatology. In talking with another physician on her team, you learn that she has also registered as a patient with her maiden name, under which she was hospitalized 3 more times in the previous year. You suspect the patient may be intentionally producing her symptoms with over-administration of her insulin. What do you do!?
1) Check a C-peptide - Naturally occurring pro-insulin requires cleavage via an enzymatic process, leaving certain levels of C-peptide as a byproduct of that reaction. Synthetic or exogenous insulin is already cleaved, and so C-peptide may be suppressed.
2) Approach the patient empathically
3) Avoid invasive treatments
4) Don't take it personally!
What is the best treatment approaches to somatic symptom disorders in general?
Psychotherapy - with focus on education, validation of symptoms, encouragement of healthy behaviors, i.e. sleep and exercise
Frequent, consistent, regularly scheduled visits with a trusted primary care physician
Pharmacotherapy for comorbidities
Conversion disorder may require hypnotherapy and/or physical & occupational therapy
A 25 year-old woman with a history of moderate anxiety and emotional abuse and neglect in childhood presents to you as a referral from her OB/GYN. She notes she is convinced she is pregnant and displays some physical signs and symptoms of pregnancy, including increased abdominal girth, exhaustion, and food cravings. However, full medical work up and gynecological confirmation has been negative, and her OB/GYN assured you she is not pregnant. About four months ago, her fiance died suddenly in a work-related accident. After ruling out all other possible causes of her symptoms, what might you consider as a diagnosis?
Pseudocyesis - false pregnancy
What movie is this? AND Name some symptoms in this scene that may be consistent with illness anxiety disorder.
What About Bob?
Calling Dr. Marvin! Dr. Leo Marvin!
Which of the following happens with each parameter in epileptic seizure versus PNES?
Consciousness?
Eyes open/closed?
Tongue biting?
Rhythmic movements?
Incontinence?
EEG findings?
Consciousness? Epilepsy +/-, PNES +
Eyes open/closed? Epilepsy - open, PNES - closed
Tongue biting? Epilepsy - +/-, PNES -
Rhythmic movements? Epilepsy +, PNES -
Incontinence? Epilepsy +/-, PNES -
EEG findings? Epilepsy +, PNES -
The typical factitious patient may have what educational experience/background?
Healthcare professionals/workers