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outline
Why do we need these changes? What are the criteria and why did we write them the way
we did?
Factitious Disorder Conversion Disorder (Functional neurological symptoms disorder) Psychological factors affecting another medical condition Somatic symptoms disorder (SSD) and illness anxiety disorder
How to assess SSD in clinical practice? How to operationalize in psychiatric epidemiology? How to convey to non-psychiatric colleagues? How to treat?
psychosomatic illnesses
Not death, but plenty of:
Disability Discomfort Dissatisfaction Destitution
comparable to depression Excessive health care use which costs US health care annually $100B Frustrating for clinicians to manage High levels of patient dissatisfaction
difficult It is always contentious, a tug of war between change and continuity DSM is not a Bible Changes driven by evolving data and utility
attention Psychological factors affecting medical condition (six variants: mental disorder, psych. symptoms, personality traits/coping style, stress-related physiological response, maladaptive health behaviors, other) Factitious Disorders With predominantly psychological signs & symptoms Factitious Dis. with predom. physical signs & symptoms Factitious Dis. with combined psych & physical symptoms Factitious Dis. NOS Appendix B Criteria sets and axes for further study Factitious Dis. By proxy
referred neurology outpatients in Scotland Of the not explained & somewhat explained
26% headache 18% conversion
Creed, Henningsen, & Fink, Medically unexplained symptoms, somatization and bodily distress, Cambridge, 2011
Out of 1,203,927 Virginia Anthem BC policy holders, only 569 somatoform cases were coded, Levenson
2011
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Clarity of diagnoses
Very clear Somatoform NOS Somatization Hypochondriasis Conversion Pain 5% 18 21 21 7 clear 22% 55 51 47 33 neutral 28% 15 15 14 23 unclear Very unclear 33% 11 11 16 26 12% 1 2 2 11
Utility of diagnoses
Very Useful useful Somatoform 6% NOS Neutral Not particularly useful Completely useless
26% 51 43 44 28
17% 16 18 17 21
42% 22 21 22 31
9% 2 5 1 12
Somatization Hypochondriasis
9 12
Conversion 17 Pain 7
27% 21 8 29 30
The BIG question: should we be emphasizing medically unexplained symptoms as the core?
rather than positive criteria Doctors disagree whether patients situation is medically unexplained
easy changes
DSM IV problems (10 codes)
Factitious disorders W psychological features W physical features W both Who is the proxy? PFAMC with 6 subtypes Mental disorder affecting Psychological symptoms affecting Personality traits or coping style Maladaptive health behaviors, Stress-related physiological response Other
Factitious disorder
imposed on self Factitious disorder imposed on another Psychological factors affecting other medical conditions- no subtypes
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Moderate changes
DSM IV problems
1. Body dysmorphic
DSM 5 solutions
1. BDD moved to obsessive
disorder (BDD) 2. Conversion 3. Location of factitious disorder (FD) and Psychological factors affecting other medical conditions (PFAMC) in the book 4. Hypochondriasis without somatic symptoms
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+s With
oma
s+ ptom m y s /c+
hypochondriasis+
Without+soma/c+symptoms+
IAD+
symptoms (MUS) Poor reliability Reinforces mind/body dualism Labels suffering as inauthentic Definition based on absence of criteria Diagnosis of a psychiatric disorder should not be based on unexplained medical symptoms Psychiatric disorders should focus on thoughts, feelings, and behaviors
between 2 different pain subtypes in DSM IV TR With new framework for SSD, that distinction less necessary. Pain is a logical specifier of SSD The more somatic symptoms, the worse the functioning, whether or not they are MUS Functioning is even worse when somatic symptoms combined with disproportionate thoughts, feelings, & behaviors
FACTITIOUS DISORDERS
disorders involving physical vs. psychological symptoms. Clarify who is the patient in factitious disorder by proxy. This is now termed factitious disorder imposed on another. Emphasize objective identification rather than inference about intentionality or possible underlying motivation.
CONVERSION DISORDER
Conversion disorder
Describes a variety of clinical phenomena Weakness, attacks, sensory deficits A relatively common diagnosis but seen more by neurologists than psychiatrists Need for simpler diagnostic criteria, easier to use, suitable
Disorder)
FNSD reflects current usage in neurology FNSD is probably more acceptable to patients
diagnoses?)
contexts.
3. Which came first, the chicken or the egg? Still dont know!
Psychological Factors Affecting Medical Condition Six DSM IV Subtypes (eliminated in DSM 5):
Mental Disorder Affecting Psychological Symptoms Affecting Personality Traits of Coping Style Affecting Maladaptive Health Behaviors Affecting Stress-Related Physiological Response Affecting Other or Unspecified Psychological Factor Affecting
diffuse, ill-defined Patients with medical illnesses can also have somatoform disorder
response to sxs, rather than cause of symptoms Extent and degree to which sxs are disruptive, disabling, distressing, bothersome Presence of medical disease does not rule out psychiatric dx; sxs could have medical basis if response disproportionate Difficulty determining definitive somatic sx etiology Mind-body dualism; sxs not either medically explained or unexplained
(e.g. muscle twitches) symptoms are viewed as signs of severe disease expects the worst outcome regardless of the evidence preoccupied by health concerns which dominate his/her life
From interview
Do you worry a lot about your health? If you notice a new bodily sensation, do you often fear that it is caused by a serious disease? When you feel your symptom, do you feel overwhelmed by it and worry it is never going to go away? Do you get the feeling that people are not taking your illnesses seriously enough? Is it hard to forget about your health and think about other things?
illness; high health anxiety but minimal or no somatic sxs; and do not qualify for anxiety disorder dx Designated IAD; negative connotations of hypochondriasis Precise relationship to existing literature on hypochondriasis unclear, source of concern and debate Somatic sx disorder section rather than anxiety disorder Focus is limited to health concerns Typically encountered in medical settings
Summary
(SSD) history from patient, relative, previous physicians Accept that SSD may occur in presence of other psychiatric disorders and general medical conditions. Treat SSD because it is an independent predictor of poor outcome. Even if concurrent depression is treated, patient may need CBT for health concerns
Symptoms) Composite International Diagnostic Interview (CIDI)(N= >30 Somatic Symptoms Physicians Health Questionnaire (PHQ-15) = 15 Somatic Symptoms past month NLAAS Somatic Symptoms (14 symptoms past year plus severity probe) SCL-12 (Hopkins Symptom Checklist) (12 symptoms, past week) SCAN-PSE Somatic Symptom Items (>80 items exploring physical symptoms).
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Pain in your arms, legs, or joints 1 Headaches? Chest pain or geGng out of breath? Dizziness? Feeling Lred or having low energy? Trouble sleeping? 1 1 1 1 1
Comorbidity Study and other recent, large, Epidemiological Studies (NIAAA Study, World Mental Health Survey) NLAAS Included an Abridged Somatic Symptom Module Similar to the PHQ-15 with Probes for Severity
DSM5 must work for non-psychiatrists, psychiatrists, and mental health researchers
A wedding cake type of
DSM?
Each layer for a different use DSM PC- still on the drawing
board (fewer disorders, briefer, guidance on stepped care) harmonization with ICD 11PC?
Nine pointers on Primary care interventions Levenstein, Psychosom Med 2007; Sapira, Ann Int
Med 1972; Smith NEJM 1986
1. 2. 3. 4. 5. 6.
Importance of patience; this is a chronic illness Elicit detailed description of symptom as well as patients worries about its significance Importance of hands on physical, even if brief and focused Avoid extensive tests Reassurance is tricky (cf Sapira, Ann Int Med 1972) Legitimize & explain symptoms:
a) b)
c)
7. 8. 9.
Its not in your head but it is real pain, but fortunately its not cancer either Sometimes these symptoms come on under stress, like a headache does, and sometimes we just dont know why they happen Some people are just more tuned into their body than others a blessing and a curse
Dont miss depression; consider antidepressants Regularly scheduled f/u appointments With established patients, selective referral in presence of distress
Referral Interventions
Specialist interventions Typically group outpatient Discussion of stress, how to recognize it and stress effects on body Homework on observing and rating stress and symptoms Learning how to communicate frustrations Exercise & relaxation
Mayou, Treatment of functional somatic symptoms, Oxford Press, 1995
Results 34 RCTs in last 40 y 4000 patients on clinical trials CBT effective in 11/13 trials Antidepressants effective in 4/5 trials Effective in terms of QoL, health care utilization
Kroenke, Psychosom Med 2007
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Next steps
Broader testing Setting the right
threshold Helping clinicians determine B criteria Defining co-occurrence with other disorders Emphasizing treatment options