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Psychology: Delusional Disorder/Somatic Symptom and Related Disorders

Terms in this set (37)

A. The presence of one (or more) delusions with a duration of __ _____ or longer.
B. Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.
Delusional Disorder: Diagnostic Criteria, 1 month
D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods.
Delusional Disorder: Diagnostic Criteria
Delusional Disorder: Diagnostic Criteria -- Specifiers

This subtype applies when the central theme of the delusion is that another person is in love with the individual.
Erotomanic type
Delusional Disorder: Diagnostic Criteria -- Specifiers

This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery.
Grandiose type
Delusional Disorder: Diagnostic Criteria -- Specifiers

This subtype applies when the central theme of the individual's delusion is that his or her spouse or lover is unfaithful.
Jealous type
Delusional Disorder: Diagnostic Criteria -- Specifiers

This subtype applies when the central theme of the delusion involves the individual's belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals.
Persecutory type
Delusional Disorder: Diagnostic Criteria -- Specifiers Two Answers

This subtype applies when the central theme of the delusion involves bodily functions or sensations.

This subtype applies when no one delusional theme predominates.
Somatic Type

Mixed Type
Usually _______ ______ is either:
-Early schizophrenia
-A secondary effect of a severe manic or depressive episode
-Related to substance effect
Delusional Disorder
Evaluation
-Evaluate for other psychiatic conditions first
-Diagnosis of exclusion

Treatment?
Delusional Disorder

Treatment
-Inpatient stabilization
-Antipsychotics
-Physical sx's that mimic a disease that isn't there.
--Psychological distress felt in a physical form
--Unconscious v. Conscious drives
-Sometimes called hysteria
-Spectrum of severity
-Are they faking?
Somatization
Some Reasons That Patients ______.
-Physical illness is socially accepted rationalization for occupational, social, or sexual failures.
-______ complaints may be a "cry" for help.
-Physical illness is less stigmatizing than mental illness.
Somatize
Reasons continued....
-Misperception.
-Playing the sick role can provide secondary gains
-disability payments
-avoiding social responsibilities.

Physical or sexual traumas during childhood appears to predispose a person to using somatic complaints for communication.
More reasons that patients somatize
More reasons.....
-May be a learned behavior.
-Physicians tend to ignore non-physical symptoms.
--CC: My back Hurts.....
--Dx: Depression
More reasons that patients somatize
Physical sx's
-Pain
-Nausea
-Headache
-Dizziness
-________
-_______
-______ ___

SYMPTOMS ARE REAL
PATIENTS ARE NOT LYING
PATIENTS FEEL WHAT THEY ARE SAYING
Somatic Symptom Disorder: Types of symptoms, Depression, Seizures, Sexual symptoms
Facts:
-Very high levels of worry about illness tend to be present
-Often think the worst about their health, even when definitive evidence to the contrary (NOT delusional, though)
-May become the central focus of their entire life
-High level of medical care utilization, generally unsatisfying though
-FEAR about health.... They can't "let it go!"
Somatic Symptom Disorder
Typical Presentation:
-Multiple symptoms
-Vague history
-History doesn't always "add up"
--No relation to exacerbating or relieving factors
-History out of proportion to exam
Somatic Symptom Disorder
All these symptoms would be considered somatic complaints

Anxiety
-Panic attacks - common features include:
--_________
--__________
--Dizziness
--Sweating
--Flushing
--Dyspnea
--Tremors
Parasthesias, Glubus Hystericus
-Depression
--1000 patients w/ dx of MDD
---69% presented with only somatic complaints
---50% had multiple unexplained complaints
-Personality disorders (Borderline)
-Substance Abuse
-Physical or sexual violence
Somatic Symptom Disorder: Who somatizes?
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
--1. Disproportionate and persistent thoughts about the seriousness of one's symptoms.
--2. Persistently high level of anxiety about health or symptoms.
--3. Excessive time and energy devoted to these symptoms or health concerns.
Somatic Symptom Disorder: Diagnostic Criteria
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than __ months).
Somatic Symptom Disorder: Diagnostic Criteria, 6 month
Specify IF:
-With ________ ____

Specify current severity:
-Mild - only one symptom in criteria B is present
-Moderate - two or more symptoms in criteria B are present
-Severe - two or more symptoms in criteria B are present PLUS there are multiple somatic complaints

Specify IF:
-________ - characterized by severe symptoms, marked impairment, and greater than 6 months duration
Somatic Symptom Disorder: Diagnostic Criteria -- Specifiers, Predominant pain, Persistent
-Other medical conditions
-Panic disorder
-Generalized anxiety disorder
-Depressive disorders
-Illness anxiety disorder
-Conversion disorder
-Delusional disorder
-Body dysmorphic disorder
-Obsessive-compulsive disorder
Somatic Symptom Disorder: Differential Diagnoses to Consider...
Evaluation:
-Thorough chart review
-Complete H&P in most cases, with psych exam worked into the physical
-Diagnosis of exclusion in most cases
Somatic Symptom Disorder
Treatment for Somatic Symptom Disorder includes?
Both psychotherapy and pharmacotherapy may be used

Usually a combination of both are tried, with the focus being on psychotherapy, as well as focused intense management by PCM
PCM practice recommendations:
-Schedule regular visits
-Establish collaborative, therapeutic alliance with the patient (don't blow them off)
-Acknowledge and legitimize symptoms as appropriate
-Coordinate care with other providers/specialists so everyone is on same page
-Evaluate and treat medical conditions which are present
Somatic Symptom Disorder & Illness Anxiety Disorder: Treatment
PCM practice recommendations:

-Limit diagnostic tests and specialist referrals, and focus on education
-MUCH reassurance that nothing has been missed
-Treat any comorbid psych diagnoses (depression/anxiety/etc.)
-CLEARLY set the treatment goal as functional improvements
-Evaluate and treat any underlying substance abuse/self-medication issues
Somatic Symptom Disorder & Illness Anxiety disorder: Treatment
What medications are the primary first-line treatment for Somatic Symptom Disorder & Illness Anxiety Disorder?
Antidepressants-SSRIs are first line, but the emphasis is on the Psychotherapy

St. John's wort
A. Preoccupation with having or acquiring a serious illness.

B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.

C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
Illness Anxiety Disorder: Diagnostic Criteria
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).

E. Illness preoccupation has been present for at least __ _____, but the specific illness that is feared may change over that period of time.
Illness Anxiety Disorder: Diagnostic Criteria, 6 months
-> Evaluate and treat just as you would for somatic symptom disorder
Illness Anxiety Disorder: Evaluation and Treatment
++++Also known as -Functional Neurological Symptom Disorder
-Uncommon, difficult to treat
-Often associated with underlying comorbid psych diagnoses
Conversion Disorder
A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

D. The symptom or deficit causes clinically significant distress
Conversion Disorder
Evaluation and Treatment of Conversion Disorder includes?
-Thorough neurologic evaluation via speciality care is essential, and may include inpatient evaluation

-Once medical causes are ruled out, assess for possibilities of secondary gain and malingering

-Once all of the above are ruled out... EDUCATION, EDUCATION, EDUCATION for the patient about conversion disorder - you have to break through the bubble

-Psychotherapy if education doesn't work; ++no meds for this condition++
May be adaptive under certain circumstances

Patient produces, simulates, or exaggerates physical illness for external gain such as disability payments, a settlement from an insurance company, or the obtaining of controlled substances.

Most common in institutional settings (i.e. sick call)
Factitious Disorder: aka Malingering
Providers are advised to document objective findings and make decisions for therapeutic interventions based on objective evidence.

Malingering is differentiated from factitious disorder by the intentional reporting of symptoms for personal gain (e.g., money, time off work). In contrast, the diagnosis of factitious disorder requires the absence of obvious rewards
Factitious Disorder: aka Malingering
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

B. The individual presents himself or herself to others as ill, impaired, or injured.

C. The deceptive behavior is evident even in the absence of obvious external rewards.
Factitious Disorder: Diagnostic Criteria
-Review the past history THOROUGHLY, look for trends and venues for secondary gain from the disorder

-Do a reasonable evaluation, which may include specialty opinions to validate/support the lack of medical illness

-DOCUMENT, DOCUMENT, DOCUMENT!
Factitious Disorder: Evaluation and Treatment
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