8/6/2014 Assessment of Psychiatric Disorders Case Vignette in the Primary Care Setting: DSM5 and Beyond A 50-year-old man with a history of 3 MDEs, but excellent response to Descartes Li, M.D. paroxetine, and stable for Clinical Professor the past year. University of Now he states that he wants to go off the California, San antidepressant because “I don’t want to Francisco be dependent on a medication.” “I don’t want to be addicted.” The Reconciliation of the Montagues and Capulets over the Dead Bodies of Romeo and How would you address these comments? Juliet by Frederick Leighton , 1855. https://www.flickr.com/photos/chris-warren-photos/6717762879/in/photolist-cihyDs-cihvP3-5YcEKc-5JDZPQ-d4HEBL-5cgJHF-5cNZ4D-9PYLs4-98PBpT-61Pfud- beChRV-hYJxyX-dah6z2-dah6XN-66asEw-666dnv-666dHK-9CBLVa-b3we6Z-gZWsU4-owXC8C-deqCYR-7VouFu-ftc1r3-bTjCta-5NNVLa-ef5r96-edkhfj-ecvngJ-ebBVZY- egUweB-ekeGGf-egbCom-o4Tb3B-8bW2Nn-mXzTyQ-8bW3jT-ak7YQj-9CBLUi-bTm4kv-7WtBar-4nbE3j-4nbGaq-4n7Bsi-4n7Bc6-4nbGuQ-fiPC5s-edCBVG-7WU6WW- foQYT8 Case Vignette How do you respond? A 29-year-old woman, with recently diagnosed OCD who presents to your office “Are antidepressants addicting?” for a follow-up visit. • Should you wait until the patient She is very reluctant to take asks? medications after consultation with a The patient states: “I don’t want to psychotherapist. However, use a crutch.” she is still symptomatic from OCD. • How do you address these concerns? She now states: “I would like to take OCD meds, but I (Hint: Better to be early, than late) think I am really sensitive to medications .” How would you address this? 1 8/6/2014 Side Effects Medication Sensitivity • “No patient has ever stopped a “Doctor, I am very sensitive to medications.” medication because of a side effect, “Hey, you’re really not sensitive. Those are unless the side effect killed him.” just common side effects.” (Shea) • What do you think the patient hears? • Importance of perception • Other potential responses? • “Given your sensitivity to medications, which are not uncommon by the way, I’d like to suggest that we start with a really low dose, a baby dose, of the medication. What do you think?” Technique: exploring medication Case Vignette sensitivity paradox of success 1. “Do you think you are particularly sensitive to A 32-year-old man with bipolar disorder, type medications?” I, had been on lithium carbonate 1200mg 2. Explore patient’s perspective: “What are some daily for one year and doing well. His most of the things that have happened that have recent labs indicated lithium level of 0.1 shown you are particularly sensitive?” mEq/L. 3. Do not challenge patient’s perspective on medication sensitivity. 4. Ask patient permission to start at a “baby He states: “I am not dose”. Remember to give rationale. sure I have bipolar disorder anymore.” What are some effective responses? 2 8/6/2014 Self Regulation and Testing Self Regulation and Testing Self-regulation as opposed to adherence: Paradox of success: individuals who stop the About half of people who are non-adherent medication when they seem to be doing perceive themselves as simply adjusting well: their own meds. “Do I still need it?” Why do people vary their medication regimes? Am I still ill?” Self-regulation How might you forestall this kind of testing? Testing (“Am I ill?”) “When people are doing well, it’s natural to *alcohol wonder if the medications are still needed. Conrad P. The Meaning of Medications: Another Look at Have you thought about that?” Compliance. Soc Sci Med. 20(1), pp29-37, 1985. Case Vignette Somatic Symptom disorders A 77yo woman is healthy except for mild hypertension and a history of chronic • Somatic symptom disorder multiple somatic complaints, for 6m, • Illness anxiety disorder preoccupied with a “heavy head”. • Conversion disorder (functional Ongoing complaints of anxiety, neurological symptom disorder) decreased energy and insomnia for the past several months or years • Factitious disorder (hx is vague). Also, Screening neuro exam is • Psychological factors affecting other medical unremarkable. Routine labs done two months ago are also conditions noncontributory. • Other (un-)specified somatic symptom and related disorder What else would you like to know to confirm diagnosis of somatic symptom disorder? 3 8/6/2014 Somatization Disorder Somatic Symptom disorders • 8 or more unexplained medical symptoms • Somatic symptom disorder (0.5% prevalence) • Illness anxiety disorder • Too complicated, required ruling out medical conditions • Conversion disorder (functional neurological symptom disorder) • “Abridged somatization”: 4 or more • Factitious disorder unexplained physical symptoms Also, 4.4% prevalence in general population • Psychological factors affecting other medical conditions 22% prevalence in primary care practice • Other (un-)specified somatic symptom and • Somatoform disorders often overlap with related disorder each other and with general medical conditions Somatic Symptom Disorder Somatic Symptom Disorder A. One or more somatic sx’s that are • May include some individuals previously distressing or disruptive of daily life diagnosed with hypochondria or B. Excessive thoughts, feelings, or behaviors somatization d/o… related to the symptoms or concerns: – Disproportionate and persistent thoughts …And may ALSO include those about seriousness individuals with major medical illness – Persistent high levels of anxiety about health (e.g. IDDM testing blood sugar 20 times – Excessive time and energy devoted to symptoms and concerns daily) C. Symptoms state is persistent (> 6mo) • Usually based on a misinterpretation Specify if: With predominant pain of bodily sensations 4 8/6/2014 Somatic Symptom disorders Anxiety Illness Disorder (includes prior diagnosis of Hypochondriasis) • Somatic symptom disorder A. Preoccupation with having or acquiring a • Illness anxiety disorder serious illness. • Conversion disorder (functional B. Somatic Sx are absent or mild. neurological symptom disorder) C. High anxiety about health, easily alarmed • Factitious disorder D. Excessive health-related behaviors or Also, maladaptive avoidance • Psychological factors affecting other medical E. >6m (but specific illness that is feared conditions may change) • Other (un-)specified somatic symptom and F. Not better explained by another disorder related disorder Specify: Care-seeking type Care-avoidant type Somatic Symptom disorders Conversion Disorder • Somatic symptom disorder • Illness anxiety disorder (aka functional neurological symptom • Conversion disorder (functional disorder) neurological symptom disorder) • Frequently sudden onset (“hysteria”) • Factitious disorder • Symptoms may include paralysis, Also, gait or coordination disturbance, • Psychological factors affecting other medical seizures (“pseudoseizures”) conditions • Other (un-)specified somatic symptom and • 13-30% later develop general related disorder medical condition 5 8/6/2014 Somatic Symptom disorders • Somatic symptom disorder • Illness anxiety disorder • Conversion disorder (functional neurological symptom disorder) • Factitious disorder Also, • Psychological factors affecting other medical conditions • Other (un-)specified somatic symptom and related disorder Factitious Disorders Somatic Symptom disorders Motivation: Motivation: Imposed on Self: exaggerated unconscious conscious symptoms associated with fantastic and improbable stories about travels Production Conversion Disorder N.A. and symptoms of (aka functional symptoms: neurological symptom unconscious disorder) Imposed on Another (by proxy) : a child or other Production Factitious Disorder Malingering of dependent is placed in sick symptoms: role conscious 6 8/6/2014 Case Vignette Management of Chronic Major A 77yo woman is healthy except for mild Somatization* hypertension and a history of chronic 1) Care Rather Than Cure multiple somatic complaints, for 6m, Don’t try to eliminate symptoms preoccupied with a “heavy head”. completely ongoing complaints of anxiety, Focus on coping and functioning as goals decreased energy and insomnia for of treatment the past several months or years 2) Diagnostic and Therapeutic Conservatism (hx is vague). Review old records before ordering tests Screening neuro exam is unremarkable. Routine labs done Respond to requests just as for patient two months ago are also who does not somatize noncontributory. Frequent visits and physical examinations Benign remedies What are the next best steps in management? (Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9) Management of Chronic Major Management of Chronic Major Somatization* Somatization* 3) Validation of Distress 4) Providing a Diagnosis Emphasize dysfunction rather than structural Don’t refute or negate symptoms pathology Patient-physician relationship not Describe amplification process and provide predicated on symptoms specific example Cautious reassurance Focus on social history Introduce stress model of disease, if appropriate Regular visits (not prn) – consider 5) Psychiatric Consultation scheduled telephone contacts To diagnose psychiatric comorbidity Once set, try not to alter the For recommendations about pharmacotherapy For cognitive-behavioral therapy to improve frequency of visits coping or psychotherapy (Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man (Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With With Multiple Somatic Complaints. JAMA 1997; 278: 673-9) Multiple Somatic Complaints.