Relevant Psychiatry for the Neurologist Financial Disclosures Focus on somatic none symptom and related disorders, plus catatonia Descartes Li, M.D. Clinical Professor University of California, San Francisco descartes.li@ucsf.edu https://commons.wikimedia.org/wiki/File:E mil_Kraepelin_1926.jpg Outline Outline • Illness Anxiety Disorder • Illness Anxiety Disorder • Conversion Disorder • Conversion Disorder – (Functional Neurological Symptom – (Functional Neurological Symptom disorder) disorder) • Factitious Disorder • Factitious Disorder • Catatonia • Catatonia 1
Case Vignette Case Vignette 41yo man with recurrent worries that he has a brain tumor. Denies any other symptoms. Repeated almost weekly visits to various physicians, numerous brain MRI scans. https://commons.wikimedia.org/wiki/File:W https://youtu.be/N4BSJ7YGClE (4min) oody_Allen_(2006).jpeg DSM-5 Criteria for Illness Anxiety Disorder A. Preoccupation with having or acquiring a serious illness. B. Somatic symptoms are not present or are only Formerly known as mild hypochondriasis C. High level of anxiety about health, and easily alarmed about personal health status. D. Excessive health-related behaviors or maladaptive avoidance E. at least 6 months F. Not better explained by another disorder. 2
Behavior Perspective What is the difference between somatic symptom disorder and Behavior illness anxiety disorder? • Both may present with anxiety • Illness anxiety disorder with no symptoms (or only mild), and fears developing an illness Choice • Somatic symptom disorder often has a medical condition with symptoms, but the reaction to these symptoms is maladaptive Consequences Rumination increased likelihood Consequent beh worsened symptoms [Somatic Symptom Disorder] Keep in mind A. Somatic Symptoms: One or more somatic • Get a careful history, including pt’s perspective. symptoms that are distressing and/or result in • Prior responses, and consequences. significant disruption in daily life. B. One or more of: Excessive thoughts, feelings, • Consider the diagnosis in individuals with multiple and/or behaviors related to these somatic complaints, such as pain, fatigue, or symptoms or associated health concerns: gastrointestinal problems. 1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms (thoughts) • Individuals often have both a diagnosed medical 2) Persistently high level of anxiety about health or condition and abnormal behaviors and thoughts symptoms (feelings) related to this condition. 3) Excessive time and energy devoted to these symptoms or health concern (behaviors) • These individuals are genuinely suffering. C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is persistent and lasts > 6 months . Questions? 3
[Examples of Disease Entities That Overlap Key rule outs with Somatic Symptom and Related for somatic symptom disorder Disorders] and related disorders Specialty Disease Entity Primary care Chronic fatigue syndrome Fibromyalgia 1. Psychosis Cardiology Atypical chest pain 2. Anxiety disorders, especially OCD Gastroenterology Irritable bowel syndrome 3. Cultural syndromes Urology Interstitial cystitis Immunology Multiple chemical sensitivities 4. Factitious disorders* ENT Temporomandibular joint syndrome Neurology Psychogenic non-epileptic seizures (Conversion disorder) Each has a different management Can be conceptualized as “contested illnesses” approach. See Dumit 2006. Illnesses you have to fight to get: Facts as forces in *separate section on factitious disorders uncertain, emergent illnesses. Social Science & Medicine 62 (2006) 577–590 2. Obsessive Compulsive 1. Psychosis Disorder – Work with psychiatrist to – If OCD is diagnosed, treat using manage delusions SSRIs/clomipramine and Exposure- – If psychosis with poor response prevention insight, recommend: I Am Not Sick, I Don't Need Help: How To Help Someone With Mental Illness Accept For OCD with disease obsession, what would Treatment, by Xavier the exposure and response prevention look Amador like? – Consider diagnoses besides schizophrenia 4
Exposure-Response Prevention 3. Cultural syndromes – May overlap Increased anxiety with “contested response prevention exposure illnesses” (eg, Morgellon’s) – Need to understand compulsions obsessions desensitization specifics of each syndrome Decreased anxiety Management of Chronic Major Management of Chronic Major Somatization* Somatization* 3) Validation of Distress 1) Care Rather Than Cure Don’t try to eliminate symptoms completely Don’t refute or negate symptoms Focus on coping and functioning as goals of Patient-physician relationship not treatment predicated on symptoms 2) Diagnostic and Therapeutic Conservatism Focus on social history Review old records before ordering tests Regular visits (not prn) Respond to requests carefully – consider scheduled telephone contacts (remember these pts often have medical conditions) Benign remedies (Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man (Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple With Multiple Somatic Complaints. JAMA 1997; 278: 673-9) Somatic Complaints. JAMA 1997; 278: 673-9) 5
Management of Chronic Major Outline Somatization* 4) Providing a Diagnosis • Illness Anxiety Disorder Emphasize dysfunction rather than pathology • Conversion Disorder Describe amplification process provide specific example, if appropriate – (Functional Neurological Symptom Cautious reassurance, dispel: disorder) “Every symptom must have an explanation” Introduce stress model of disease, if appropriate • Factitious Disorder 5) Mental Health Consultation • Catatonia To diagnose psychiatric comorbidity For recommendations about pharmacotherapy For cognitive-behavioral therapy to improve coping or psychotherapy (Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9) What Happened to the https://youtu.be/cCED0PQqXZg Girls in Le Roy? Case Vignette http://www.nytimes.com/2012/03/11/magazine/teenage-girls- twitching-le-roy.html 16yo girl with new onset tics 6
DSM-5 Criteria for Conversion Disorder What Happened to the Girls in Le Roy? (Functional Neurological Symptom Disorder) A. One or more symptoms of altered voluntary motor or sensory function . B. Incompatibility between the symptom and recognized neurological or medical conditions . C. Is not better explained by another medical or mental disorder. D. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Specify symptom type: abnormal movement, seizures, speech, sensory loss, etc. Specify if: acute or persistent Specify if: with or without psychological stressor (specify stressor) http://www.nytimes.com/2012/03/11/m agazine/teenage-girls-twitching-le- roy.html Hystero-epilepsy History of conversion disorder DSM-II: Hysterical neurosis Hysteria psychosomatic somatoform History of the DSM DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994) the DSM-II, hysterical neurosis Jean-Martin Charcot 1825-1893 DSM-5 (2013) 7
Other examples of conversion Characteristics of PNES disorder 1. triggered by stress • psychogenic non-epileptic seizures 2. no incontinence (PNES) aka pseudoseizures 3. no post-ictal confusion • Sudden paralysis of right upper 4. speaking during the episode extremity 5. >10minutes • Sudden onset of unilateral hearing loss 6. always witnessed • Also hysterical blindness, incontinence 7. resolution with psychosocial interventions Risk factors How do you treat Conversion disorder? 8
http://www.neurosymptoms.org/ conversion disorder Conversion disorder management management • Can be very useful to be straightforward and educational • Attitude and word choice may be key • Reassure that condition usually resolves with treatment (PT, stress reduction) • However, conversion may overlap with management of factitious https://vimeo.com/ disorder The Fringe 2015: Hidden World of 136982979 Functional Disorders 9
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