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The Unexplained Physical Symptom

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Experiencing and reporting bodily symptoms that have no pathological basis, ... Factitious Disorder. Intentional production or feigning of symptoms ... – PowerPoint PPT presentation

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Title: The Unexplained Physical Symptom


1
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

2
Outline
  • Unexplained symptoms
  • Definitions of conditions
  • Management

3
Unexplained symptoms
  • 25-50 No serious medical cause found
  • 30-75 Remain medically unexplained
  • 16-33 bothered the patient a lot
  • but remain unexplained

4
Somatization Other Psychiatric Disorders
  • Men 3 unexplained symptoms
  • Women 5 unexplained symptoms
  • Katon 1999

5
Multiple unexplained physical symptoms
  • Major Depression and Dysthymia
  • Panic Disorder
  • GAD
  • OCD
  • Somatoform Disorders
  • Substance abuse
  • Brown 1990

6
Somatization Definition
  • Experiencing and reporting bodily symptoms that
    have no pathological basis, attributing them to
    disease and seeking medical attention for them
  • Lipowski 1988

7
Somatization Disorder
  • Symptoms begin before age 30
  • 4 pain
  • 2 GI
  • 1 sexual
  • 1 pseudoneurological
  • DSM-IV

8
Undifferentiated Somatoform Disorder
  • 1 or more unexplained somatic symptom
  • 6 month duration
  • DSM-IV

9
Symptom Amplification
  • Belief one has a serious illness
  • Expectation that symptoms will worsen
  • The sick role
  • Condition is catastrophic and disabling
  • Barsky 1999

10
Hypochondriasis
  • Misinterpretation or amplification of bodily
    symptoms
  • Unreasonable fears or expectations of disease
  • 6 months duration
  • Impairment of functioning
  • DSM-IV

11
Major Somatization
  • Chronic
  • Multiplicity of symptoms
  • Refractory to reassurance
  • Absence of discrete stressor
  • Disproportionate disability and role impairment
  • Pursuit of medical care
  • Barsky 1997

12
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

13
Malingering
  • Intentional production of exaggerated or false
    symptoms
  • Motivated by secondary gain
  • Conscious
  • DSM-IV

14
Factitious Disorder
  • Intentional production or feigning of symptoms
  • Motivation is to assume the sick role
  • No obvious secondary gain
  • DSM-IV

15
Six-step strategy
  • Rule out major medical problem
  • Rule out major psychiatric problem
  • Build collaborative alliance
  • Barsky 1999

16
Six-step strategy
  • Improved functioning and coping are the goals
  • Provide limited reassurance
  • CBT if no success from above measures
  • Barsky 1999

17
Rule out medical problem
  • Reasonable work up
  • Explain how the test results change the treatment
    (if they do at all)
  • Avoid well if we dont find anything then Ill
    refer
  • Barsky 1999

18
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

19
Collaborative alliance
  • Somatizing patients want medical care
  • Fear rejection or invalidation of symptoms
  • Validate dysfunction and suffering

20
Functioning is the goal
  • Shift Expectations
  • Symptom reduction
  • Improved functioning
  • NOT
  • Diagnosis
  • Eradication of symptoms

21
Limited Reassurance
  • Instill hope
  • Acknowledge that we may miss something, but this
    is very unlikely
  • More frequent non-emergent visits

22
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

23
Case
  • 37 year old man with multiple somatic complaints
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