* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Document
Substance use disorder wikipedia , lookup
Obsessive–compulsive personality disorder wikipedia , lookup
Mental disorder wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
Memory disorder wikipedia , lookup
Bipolar disorder wikipedia , lookup
Conduct disorder wikipedia , lookup
Combat stress reaction wikipedia , lookup
Child psychopathology wikipedia , lookup
Symptoms of victimization wikipedia , lookup
Bipolar II disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Sluggish cognitive tempo wikipedia , lookup
Rumination syndrome wikipedia , lookup
Spectrum disorder wikipedia , lookup
Panic disorder wikipedia , lookup
Treatment of bipolar disorder wikipedia , lookup
Depersonalization disorder wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Asperger syndrome wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Depression in childhood and adolescence wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Factitious disorder imposed on another wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Post-concussion syndrome wikipedia , lookup
Munchausen by Internet wikipedia , lookup
Diagnosis of Asperger syndrome wikipedia , lookup
The Unexplained Physical Symptom Robert K. Schneider, MD Assistant Professor Departments of Psychiatry, Internal Medicine and Family Practice Virginia Commonwealth University The Medical College of Virginia Campus Outline • Unexplained symptoms • Definitions of conditions • Management Unexplained symptoms 25-50% No serious medical cause found 30-75% Remain medically unexplained 16-33% “bothered the patient a lot” but remain unexplained Somatization: Other Psychiatric Disorders • Men: 3 unexplained symptoms • Women: 5 unexplained symptoms Katon 1999 Multiple unexplained physical symptoms • • • • • • Major Depression and Dysthymia Panic Disorder GAD OCD Somatoform Disorders Substance abuse Brown 1990 Somatization: Definition Experiencing and reporting bodily symptoms that have no pathological basis, attributing them to disease and seeking medical attention for them Lipowski 1988 Somatization Disorder • Symptoms begin before age 30 –4 pain –2 GI –1 sexual –1 pseudoneurological DSM-IV Undifferentiated Somatoform Disorder • 1 or more unexplained somatic symptom • 6 month duration DSM-IV Symptom Amplification • Belief one has a serious illness • Expectation that symptoms will worsen • The “sick role” • Condition is catastrophic and disabling Barsky 1999 Hypochondriasis • Misinterpretation or amplification of bodily symptoms • Unreasonable fears or expectations of disease • 6 months duration • Impairment of functioning DSM-IV Major Somatization • • • • • Chronic Multiplicity of symptoms Refractory to reassurance Absence of discrete stressor Disproportionate disability and role impairment • Pursuit of medical care Barsky 1997 Conversion Disorder • 1 or more symptom affecting motor or sensory functioning that suggests a neurological or general medical disorder • Association with psychological stressor • Unconscious defense DSM-IV Malingering • Intentional production of exaggerated or false symptoms • Motivated by secondary gain • Conscious DSM-IV Factitious Disorder • Intentional production or feigning of symptoms • Motivation is to assume the sick role • No obvious secondary gain DSM-IV Six-step strategy • Rule out major medical problem • Rule out major psychiatric problem • Build collaborative alliance Barsky 1999 Six-step strategy • Improved functioning and coping are the goals • Provide limited reassurance • CBT if no success from above measures Barsky 1999 Rule out medical problem • “Reasonable” work up • Explain how the test results change the treatment (if they do at all) • Avoid “well if we don’t find anything then I’ll refer” Barsky 1999 Rule out psychiatric disorder • MAPS-O is helpful in getting the spectrum of symptoms (MDD, Panic) • Symptom focus as opposed to disorder focus • Use Balint Agreement Collaborative alliance • Somatizing patients want medical care • Fear rejection or invalidation of symptoms • Validate dysfunction and suffering Functioning is the goal Shift Expectations • Symptom reduction • Improved functioning NOT • Diagnosis • Eradication of symptoms Limited Reassurance • Instill hope • Acknowledge that we may miss something, but this is very unlikely • More frequent non-emergent visits CBT • Good evidence supports its usage in the major somatization group or highly impaired functional disorders • Can be applied individually but groups are very effective and efficient Case 37 year old man with multiple somatic complaints