Lecture 4

• Somatic Symptom and Related Disorders (SSRD)

  Somatic symptom disorder

  illness anxiety disorder

  Conversion disorders / Functional Neurologic Disorders (FND)

  Factitious disorder/ Münchhausen syndrom

  Psychological factors affecting other medical conditions
• Illness


  Cluster of symptoms or complaints

  • It has a specific (organic) cause
  • A defined course
  • A specific outcome
• A symptom can be part of …

  Disease : biological / medical substrate

  Disorder : disturbances, typically with a known biomedical underpinning, but not necessarily (e.g., depression)

  Illness : the feeling of being ill (self-report)

  Sickness : not fulfiling social roles, calls sick at work, limited functioning, patient role
• Psychological disorder: syndrome


  Research suggests that 17% of patients under the care of general physicians (family physician) display physical symptoms that have no apparent physical cause
• Psychological disorder: syndrome (as link between outcomes)


  • Cluster of symptoms (and signs) that co-occur more often than expected by chance (not ‘at random’); often without a clear cause / pathology

  • Represents non-normal behavior or experiences, the symptoms belong together.

  • Clusters are clearly defined (recognizable) and saliently

  different from other clusters.

  • Purely descriptive, the (somatic) cause is not necessarily

  known
• Notions of pathology


  :

  
• Biopsychosocial model


  by Engel

  = cultural norms on how to express both physical & mental symptoms

  
• Predisposing


  “Why me?"

  -> genetic vulnerability

  -> early life exposure
• Precipitating


  “Why now?”

  -> extreme emotions e.g. being very angy -> heart attack

  so: different triggers
• Perpetuating


  “Why still?”

  -> how can you prevent it
• The biopsychosocial model


  :

  
• Somatic Symptom Disorder (SSD) and related disorders (SSRD)

  • Somatic symptom disorder (SSD)

  • Illness anxiety disorder (in DSM-IV: hypochondriasis)

  • Conversion disorder / Functional Neurological (symptom) Disorder

  • Factitious disorder (imposed on self versus imposed on

  another)

  • Other specified somatic symptom and related disorder

  • Unspecified somatic symptom and related disorder
• Somatic symptom disorder (SSD)

  • One or more somatic symptoms that are distressing or result in significant disruption of daily life.
  • Excessive thoughts, feelings, or behaviors related to the somatic symptoms
  • complaints for more than 6 months
• Somatic symptom disorder (SSD)- symptoms


  •Disproportionate and persistent thoughts about the seriousness of vone’s symptoms (cognitions)

  •Persistently high level of anxiety about health or symptoms (affect)

  •Excessive time and energy devoted to these symptoms or health concerns (behavior)
• SSD- specifications


  • With predominant pain (previously “pain disorder”)

  • Persistent

  • Mild

  • Moderate

  • Severe
• SSD- specification- with predominant pain


  This specifier is for individuals whose somatic symptoms predominantly involve pain
• SSD - specification- persistent


  a persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months)
• SSD - specification- mild, moderate, severe


  • Mild: Only one of the symptoms specified in Criterion B is fulfilled.

  • Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

  • Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom)
• How prevalent is SSD?

  • Estimated: 5-7% (exact % still unknown)

  • Expectation: higher than thaf for somatization disorder (<1%)

  • Lower than that of the undifferentiated somatoform disorder (19%)

  • More common in women than men

  • Possibly more common in people with medical disorders
• “Medically Unexplained” Somatic Symptoms (MUSS)

  • somatic symptoms for > couple weeks, without medical/ biological substrate/ deficit to sufficiently explain the complaints
  • considered ‘working hypothesis’ based on the (demonstrable) premise that somatic or psychological pathology has been ruled out
  • similar to: “Functional Somatic Disorder” (FSD), “Functional Somatic Symptoms”
• “Functional Somatic Disorder” (FSD)), “Functional Somatic Symptoms”


  examples: Non-cardiac chest pain, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome

  -> all symptoms interfere with functions, so: functional somatic symptoms

  • ppl with this: s often do not appreciate a psychological explanation of (part of) their symptoms, often prefer a somatic causal explanation
  • Persistent Physical Symptoms (PPS) -> currently preferred terminology
• Most common symptoms of MUSS/ FSD/ PPS


  Headache, backache, pain in joints, stomach ache, fatigue, nausea
• Functional somatic disorders (MUSS / PPS)


  main complaints & syndrome

  
• Comorbidity


  • Frequent, both psychological as physical

  More somatic symptoms → higher prevalence of anxiety

  and depressive disorders
• General Practitioner’s Perspective- in diagnosis

  • Internal Medicine Referral: colonoscopy showed normal results

  ↓

  • Irritable Bowel Syndrome

  ↓

  • Diet advices

  ↓ if symptoms continue to last:

  • Referral to the psychologist (if patient experiences more than usual burden)
• Illness anxiety disorder

  • fear of serious illness
  • no somatic symptoms(if present -> low intensity)
  • preoccupation = excessive/ disproportionate if other medical condition present/ risk for it (e.g. strong family history)
  • high level of anxiety about health
  • excessive health-related behaviours (e.g. repeated health checks) or maladaptive avoidance (e.g. avoidance of doctor appointments)
  • present for at least 6 months
  • not better explained by another mental disorder
• Converson disorder / Functonal Neurological Disorder (FND)

  • One or more symptoms of altered voluntary motor or sensory function
  • incompatibility between symptoms & neurological/ medical conditions clinically recognized
  • not better explained by another medical/ mental disorder
  • symptom causes clinically significant distress/ impairment in social, occupational, or other important areas of functioning or warrants medical evaluation
• Specify symptom type


  • With weakness or paralysis * With attacks or seizures

  • With abnormal movement * With anesthesia or sensory loss

  • With swallowing symptoms * With special sensory symptom

  • With speech symptom * With mixed symptoms

  -> Often triggered by emotional event (trauma)
• Factitious disorder

  Münchausen syndrome

  • Falsification of physical/ psychological symptoms; induction of injury/ disease, associated with identified deception
  • The individual presents themselves to others as ill, impaired, or injured
  • behavior present even with no obvious external rewards
  • not better explained by another mental disorder (e.g. delusional disorder, other psychotic disorder)
• Factitious disorder- 2 types

  • Imposed on self (Münchausen syndrome)

  • Imposed on another (Münchausen syndrome by proxy)

  -> Clients often knowledgeable about medicine

  -> Willing to endure substantial pain or medical procedures

  -> Recurrent use of different medical care facilitities/doctors (to not get caught)
• Factitious disorder by proxy

  • Not the person her/himself, but a dependent (often a child) is injured or poisened to get medical attention

  • Caregiver often “protective” and common with some medical background

  • Reasons for engaging in this behavior similar as self-induced factitious consequences of disorder
• What is the difference between factitious disorder and simulation/malingering?

  difficult to distinguish bc simulation(falsification) = part of the definition of factitious disorder

  • The motivation for falsification is to become a ‘patient’ →

  factitious disorder

  • External rewards motivates the behavior → malingering
• Psychological factors affecting other medical conditions

  • medical symptom or condition (other than a mental disorder) is present
  • Psychological or behavioral factors adversely affect the medical condition in different ways
  • psychological and behavioural factors not better explained by another mental disorder (e.g., panic disorder, major depressive disorder, posttraumatic stress disorder)
• how do Psychological or behavioral factors adversely affect the medical condition?

  – factors have influenced course of medical condition as shown by close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition

  – interfere with the treatment of the medical condition (e.g., poor adherence)

  – constitute additional well-established health risks for individual

  – influence underlying pathophysiology, precipitatin, exacerbating symptoms or necessitating medical attention
• Specify current severity of Psychological factors affecting other medical conditions

  • Light: Increases medical risk (e.g., inconsistent adherence with antihypertension treatment).

  • Mild: Aggravates underlying medical condition (e.g., anxiety aggravating asthma).

  • Moderate: Results in medical hospitalization or emergency room visit.

  • Severe: Results in severe, life-threatening risk (e.g., ignoring heart attack symptoms)
• “The” SSRD patient


  • Long history of searching an answer, endlessly in assessment

  • Little trust in health care and clinicians

  • Highly (self) critical, perfectionist, competitive

  • More often women

  • Low SES (=Socioeconomic status), smaller social network

  • Often traumatic experiences in the past

  • Difficulties with mentalization
• Mentalization


  = : the ability to understand the mental state - of oneself or others - that underlies behavior

  • Bodily focused mentalization: deducing emotions from bodily sensations
• What could it mean for the therapeutic interaction?

  • Complain, reject treatment

  • Feels rejected

  • Misunderstandings

  • Difficult to structure all the information

  • Rejects psychological perspective
• Thories of SSR


  Psychodynamic Theory, Cognitive Behavioral Theory, Cultural-Oriented Theory
• Theories of SSRD-Cultural-Oriented Theory

  Cultures differ in ‘psychopathologizing’ the expression of emotions as somatic symptoms: Industrialized countries typically pathologize somatic expression of emotion

  E.g., in Chinese culture the expression of sadness is often stigmatized more that somatization