DSM 5 SOMATIC SYMPTOM AND RELATED DISORDERS: SAME OLD, ONLY EASIER Inés Monguió, Ph.D. American College of Forensic Psychology 2014, San Diego DSM-IV-TR Somatoform Disorders - Somatization Disorder - Undifferentiated Somatoform Disorder - Conversion Disorder - Pain Disorder (w/ Psych Factors, or both psych and general medical condition) - Hypochondriasis - Body Dysmorphic Disorder - Somatoform Disorder NOS Factitious Disorders - W/ predominant psych Sy - W/ predominant physical Sy - W/ combined psych and phys Sy And of course, Factitious Disorder NOS Psychological Factors Affecting Medical Conditions Malingering Somatoform Disorders Somatization Disorder - Multiple symptoms/medical complaints that begin before age 30 - Duration of years - Pain (4), GI (2), sexual (1), and (1) pseudoneurological symptoms/complaints must be present DSM 5 Somatic Symptoms Disorders ACFP 2014 Page 2 of 10 - No full medical explanation - If general medical condition is present, the complaints and disability are excessive Undifferentiated Somatoform Disorder - One or more physical complaints without known medical bases lasting 6+ months - If medical condition is present, complaints and/or disability are excessive Conversion Disorder - Symptoms, often neurologic, involving sensory functions or voluntary muscles - No medical explanation - Not voluntary/feigned - Sy not limited to pain or sexual dysfunction - Psychological factors associated with symptoms Pain Disorder (w/ Psych Factors, or both psych and general medical condition) - Pain is main complaint - Psychological factors involved in onset, severity and/or maintenance - May involve actual tissue damage or change Hypochondriasis - Anxiety is characteristic - Preocupation or obsessive ideation of poor health - Misinterpretation of bodily symptoms and functions Body Dysmorphic Disorder - Preoccupation with imagined or exaggerated defect in physical appearance [JACKO?] Somatoform Disorder NOS - Junk drawer for anything else DSM 5 Somatic Symptoms Disorders ACFP 2014 Page 3 of 10 [NOTE: RSD, CPRS, fibromyalgia] Factitious Disorders - W/ predominant psych Sy - W/ predominant physical Sy - W/ combined psych and phys Sy And of course, Factitious Disorder NOS Psychological Factors Affecting Medical Conditions Malingering Problems with Above DSM-IV Diagnoses - Huge overlap among diagnoses - Poor specificity - Often Dx distinctions were irrelevant for treatment or prognosis - Except for Malingering, all other Dx reinforced soma psyche dualism - Patient usually resisted Dx as meaning “all in your head” Changes in the DSM 5 DSM 5 does simplifies diagnostic considerations. - The main issue becomes that the presentation is one of primarily physical complaints. - Recognizes that “unexplained medical causes” is quite limited a criteria - Acknowledges cultural and personal factors in experience and expression of symptoms Somatic Symptom Disorder Subsumes former Pain Disorder, both Somatization Disorders, and the majority of Hypochondriasis - One or more somatic Sy cause distress or disruption in daily life DSM 5 Somatic Symptoms Disorders ACFP 2014 Page 4 of 10 - Persistent distressing thoughts and/or feelings regarding seriousness of Sy, or excessive time/energy devoted to Sy. - Persistent symptom presentation, although specific sy may change - Specifiers include “with predominant pain”, Persistent” (more than 6 months), and degree of severity. Illness Anxiety Disorder Subsumes Hypochondriasis in the minority of cases in which the individual does not present with somatic complaints. - Somatic Sy may not be present or only mildly - Preoccupation with having or getting a serious illness. Lasting at least 6 months - High level of anxiety regarding health - Excessive health related behaviors or avoidance of same Specifiers include “Care-seeking type” and “Care-avoidant type”. Conversion Disorder (Functional Neurological Symptoms Disorder) - One or more Sy of altered voluntary motor or sensory function - Sy are incompatible with extant medical knowledge - Sy or deficit cause distress OR impairment in important areas of functioning - Other conditions do not better explain Sy Of note, the excessive thoughts, feelings, and behaviors present in Somatic Symptoms Disorder is usually absent. Psychological Factors Affecting Medical Condition - Psychological or behavioral factors affect a present medical symptoms or condition in development, exacerbation, or recovery - The factors interfere with treatment, - Or constitute health risks for the individual - Or influence underlying pathophysiology Any one of the conditions above, if present with a medical condition and not better explained by another mental disorder, merits the diagnosis DSM 5 Somatic Symptoms Disorders ACFP 2014 Page 5 of 10 Factitious Disorders Imposed on Self/Imposed on Another - Falsification of physical or psychological Sy, or induction of injury or disease - Presentation of self (or other) as ill, impaired, or injured - Deception appears to have no obvious external rewards - Not delusional disorder or psychotic disorder explains behavior Malingering - Characterized by intentional production of false or exaggerated symptoms motivated by external incentives (for financial gain or avoiding work, responsibility, punishment) - Suspect in medicolegal context, with poor cooperation, or if presentations and findings are markedly discrepant. - Definite evidence of feigning would suggest factitious disorder if aim is an external incentive - Different from factitious disorder in external vs internal incentives for behavior - Different from conversion disorder and somatic disorder by the intentional production of symptoms and obvious external incentives. CASE STUDIES Case #1: I fell and can’t get up - Female, 53, married with grown children. - Claimed excellent grades in school - Excellent (!) family support - Denies problems in relationships - Healthy, but Hx of being high strung - Looked older than stated age - Fell and hit head on metal machinery at work. No LOC but dazed. - Grown children drove her to hospital. Released home a few hours later - Seven years post accident the patient complained of constant dizziness that prevented her from walking the streets unaccompanied - Constant disabling headaches, knee and back pain that prevented all ADLs including driving - Problems with memory, attention, and information processing DSM 5 Somatic Symptoms Disorders ACFP 2014 Page 6 of 10 - Agitation, depression, and anxiety - Two episodes of syncope-like events that she described as “epileptic- like” - Another psychologist diagnosed her and treated her for Major Depressive Disorder, single episode, mild, and Cognitive Disorder NOS, and Pain Disorder with physical and psych factors. Anxiety was mentioned on reports but not integrated into diagnosis. - Medication included gabapentin 100, doxepin 25, alprazolam 0.5 and Tramadol 50 TEST RESULTS for Case #1 CARB 41.3% correct Rey 15 8 correct WAIS-III-M VIQ 66; PIQ 69; FIQ 60; WOI 89, VCI 70, POI 69, PSI 62 Color Trails T = <20, 20 BNE Visual Memory all <1st %ile but for immediate (T = 37, 24th %ile) Verbal Memory for paragraphs T = 28-33 except for immediate, T = 43 List Learning T = 45 (list B) to 34 (Recognition) Visual Attention T 24 and 26 Verbal Attention T 24 and 38 Stroop Word T 21, Color T 16, Color/Word T 24 WCST Only 5 PSV, 0 categories, 88 errors FAS 17 total, no repetitions, T = 34. MMPI-2 Clear effort to “look good”, relatively mild “fake bad” scale. Elevation of F likely reflecting occasional willingness to admit distress. Psychological Distress appears genuine. Profile 238*1” DSM 5 Diagnoses -Major Depressive Disorder, mild, recurrent -Generalized Anxiety Disorder -Panic Disorder DSM 5 Somatic Symptoms Disorders ACFP 2014 Page 7 of 10 -Somatic Symptom Disorder, persistent, moderate -Dependent Personality Disorder with Histrionic features and Narcissistic and Avoidant trends Case #2 “Just like in the novelas” - 55 year old woman in 2011. Evaluated first in 2008 - Fell at work cleaning houses and hit her head. Denies any memory of when or how and woke up at hospital. But remembers the dog of the house licked her face while she laid on the floor. - Bizarre presentation of cognitive deficits - In 2008 the husband first and later the adult children were very confrontational with office staff and with me (STM seemed to be working fine!) - In 2011 the husband was very angry at her and declared he could not stand her any more - Denied health or mental health problems before injury - “Perfect” history, life, and family - Curiously, defined her ethnic background as “white” - Outwardly polite and cooperative but NO INFO - At one point she appeared positively wily when I showed my frustration TEST RESULTS for Case #2 First Evaluation CARB: 37.3 correct. WMT: 25.5 Correct Rey 15: 4/15 WAIS-III-M: VIQ: 66 PIQ: 60 FSIQ: 60 Raven SPM: 7/60 4th percentile WHO-UCLA Rey CFT: Copy: Unscorable Recall: Unscorable DSM 5 Somatic Symptoms Disorders ACFP 2014 Page 8 of 10 Considering exaggeration and feigning, it was difficult to ascertain if true cognitive sequelae of concussion. The family was very protective. She was very low functioning (not functioning) in all areas. Axis I Factitious Disorder with Predominant Physical Signs and Symptoms R/O Malingering Axis II Deferred. Not enough info. Schizoid, Avoidant, dependent, narcissistic and histrionic features Second Evaluation SIRS-2: Disengaged (feigning) MMPI-2 Did not cooperate Rorschach: High situational stress, low psych resources, cognitive deficits, unsophisticated and simplistic.