Diferencia entre revisiones de «Somatic symptom disorder»
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==Background== | ==Background== | ||
* Somatic symptoms associated with distress and impairment that cannot be medically explained | *Somatic symptoms associated with distress and impairment that cannot be medically explained | ||
** Most common symptom is pain — may be specific, generalized, or nonspecific (eg, [[fatigue]]) | **Most common symptom is pain — may be specific, generalized, or nonspecific (eg, [[fatigue]]) | ||
** May represent normal bodily sensations (eg, [[borborygmus]]) | **May represent normal bodily sensations (eg, [[borborygmus]]) | ||
** May occur concurrently or secondarily to a medical condition | **May occur concurrently or secondarily to a medical condition | ||
* Typically encountered in primary care and other medical settings | *Typically encountered in primary care and other medical settings | ||
** Less commonly encountered in psychiatric and other mental health settings | **Less commonly encountered in psychiatric and other mental health settings | ||
==Clinical Features== | ==Clinical Features== | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
* Medical conditions | *Medical conditions | ||
** [[Irritable bowel syndrome]] | **[[Irritable bowel syndrome]] | ||
** [[Fibromyalgia]] | **[[Fibromyalgia]] | ||
** Endocrine disorders | **Endocrine disorders | ||
*** [[Hyperparathyroidism]] | ***[[Hyperparathyroidism]] | ||
*** [[Thyroid]] disorders | ***[[Thyroid]] disorders | ||
*** [[Addison's disease]] | ***[[Addison's disease]] | ||
*** [[Insulinoma]] | ***[[Insulinoma]] | ||
*** [[Panhypopituitarism]] | ***[[Panhypopituitarism]] | ||
** Poisonings | **Poisonings | ||
*** [[Botulism]] | ***[[Botulism]] | ||
*** [[Carbon_monoxide_toxicity|carbon monoxide]] | ***[[Carbon_monoxide_toxicity|carbon monoxide]] | ||
*** [[Heavy metals]] | ***[[Heavy metals]] | ||
** [[Porphyria]] | **[[Porphyria]] | ||
** [[Multiple sclerosis]] | **[[Multiple sclerosis]] | ||
** [[Systemic lupus erythematosus]] | **[[Systemic lupus erythematosus]] | ||
** [[Eponyms_(T-Z)#Wilson.27s_disease|Wilson's disease]] | **[[Eponyms_(T-Z)#Wilson.27s_disease|Wilson's disease]] | ||
** [[Myasthenia gravis]] | **[[Myasthenia gravis]] | ||
** [[Eponyms_(F-L)#Guillain-Barr.C3.A9_syndrome|Guillain-Barré syndrome]] | **[[Eponyms_(F-L)#Guillain-Barr.C3.A9_syndrome|Guillain-Barré syndrome]] | ||
** [[Uremia]] | **[[Uremia]] | ||
* Psychiatric conditions | *Psychiatric conditions | ||
** [[Panic_attack|Panic disorder]] | **[[Panic_attack|Panic disorder]] | ||
** [[Generalized anxiety disorder]] | **[[Generalized anxiety disorder]] | ||
** [[Depression|Depressive disorders]] | **[[Depression|Depressive disorders]] | ||
** [[Illness anxiety disorder]] | **[[Illness anxiety disorder]] | ||
** [[Conversion disorder]] | **[[Conversion disorder]] | ||
** [[Delusional disorder]] | **[[Delusional disorder]] | ||
** [[Body dysmorphic disorder]] | **[[Body dysmorphic disorder]] | ||
** [[Obsessive-compulsive disorder]] | **[[Obsessive-compulsive disorder]] | ||
** [[Factitious disorder]] | **[[Factitious disorder]] | ||
** [[Malingering]] | **[[Malingering]] | ||
==Evaluation== | ==Evaluation== | ||
* Screen for organic causes of symptoms | *Screen for organic causes of symptoms | ||
* Psychiatric consultation | *Psychiatric consultation | ||
==Management== | ==Management== | ||
===Reassurance=== | ===Reassurance=== | ||
* May be successful in young patients with no underlying medical or psychiatric illnesses with clear psycho-social stress | *May be successful in young patients with no underlying medical or psychiatric illnesses with clear psycho-social stress | ||
* Unlikely to be successful in patients with chronic somatization | *Unlikely to be successful in patients with chronic somatization | ||
** Perceived as denial of sick role | **Perceived as denial of sick role | ||
** Desire for acknowledgment and recognition → disappointment when no pathology discovered | **Desire for acknowledgment and recognition → disappointment when no pathology discovered | ||
** Resistance to recovery because "specter of cure" threatens sick role | **Resistance to recovery because "specter of cure" threatens sick role | ||
*** Development of new side effects, allergic reactions, and symptoms | ***Development of new side effects, allergic reactions, and symptoms | ||
===Legitimization of Symptoms=== | ===Legitimization of Symptoms=== | ||
* Listen and attempt to understand patient's experience | *Listen and attempt to understand patient's experience | ||
* Explain that patient's illness causes many symptoms but does not lead to medical deterioration | *Explain that patient's illness causes many symptoms but does not lead to medical deterioration | ||
* Offer only guarded projections about patient's condition → safeguards sick role → may limit illness behavior | *Offer only guarded projections about patient's condition → safeguards sick role → may limit illness behavior | ||
===Diagnosis=== | ===Diagnosis=== | ||
* Clarify precise meaning of terms to avoid misinterpretation | *Clarify precise meaning of terms to avoid misinterpretation | ||
* Somatic responses and descriptions may be better accepted than purely psychiatric diagnoses | *Somatic responses and descriptions may be better accepted than purely psychiatric diagnoses | ||
** Hyperventilation, tension headache, muscle tension, muscle strain, muscle spasm, and stress | **Hyperventilation, tension headache, muscle tension, muscle strain, muscle spasm, and stress | ||
* Communicating diagnostic uncertainty may be helpful | *Communicating diagnostic uncertainty may be helpful | ||
** "atypical pain", "multiple complaints following injury" | **"atypical pain", "multiple complaints following injury" | ||
===Medications=== | ===Medications=== | ||
* Patient with somatic symptom disorder have a high affinity for medications and are reluctant to discontinue drugs, regardless of benefit | *Patient with somatic symptom disorder have a high affinity for medications and are reluctant to discontinue drugs, regardless of benefit | ||
** Prioritize lifestyle modification | **Prioritize lifestyle modification | ||
** Benign remedies may be helpful — lotions, supplements, elastic bandages, and heating pads | **Benign remedies may be helpful — lotions, supplements, elastic bandages, and heating pads | ||
* Avoid drugs that cannot be safely continued indefinitely | *Avoid drugs that cannot be safely continued indefinitely | ||
* Avoid drugs that produce abstinence syndromes or dependence | *Avoid drugs that produce abstinence syndromes or dependence | ||
* Avoid pain medications; if necessary, prescribe to be take on schedule, not "as needed" | *Avoid pain medications; if necessary, prescribe to be take on schedule, not "as needed" | ||
* Antidepressants may be beneficial, including tricyclics | *Antidepressants may be beneficial, including tricyclics | ||
===Mental Health Consultation=== | ===Mental Health Consultation=== | ||
* Patients resist psychiatric evaluation — threatens sick role | *Patients resist psychiatric evaluation — threatens sick role | ||
* Patients fear abandonment → reassure primary physician will continue caring for them | *Patients fear abandonment → reassure primary physician will continue caring for them | ||
* Patients may accept treatment as "stress management" or "education" that targets physical symptoms and somatic distress. | *Patients may accept treatment as "stress management" or "education" that targets physical symptoms and somatic distress. | ||
===Physician Attitudes=== | ===Physician Attitudes=== | ||
* Focus on understanding patient's subjective experience | *Focus on understanding patient's subjective experience | ||
** Avoid telling patient nothing is wrong or symptoms require no treatment | **Avoid telling patient nothing is wrong or symptoms require no treatment | ||
* Avoid counter-transference when no physiologic explanation can be found | *Avoid counter-transference when no physiologic explanation can be found | ||
** Attempt to retain compassion | **Attempt to retain compassion | ||
** Don't label as "difficult patient" | **Don't label as "difficult patient" | ||
===Treatment Goals=== | ===Treatment Goals=== | ||
* Patients lack insight. Do not attempt insight-oriented psychotherapy. | *Patients lack insight. Do not attempt insight-oriented psychotherapy. | ||
* Do not promise or attempt cure — threatens sick role | *Do not promise or attempt cure — threatens sick role | ||
** Patient may escalate illness behaviors — new side effects, allergic reactions, and symptoms | **Patient may escalate illness behaviors — new side effects, allergic reactions, and symptoms | ||
** Reassure that patient will "probably always be ill" and should "learn to live with some pain" | **Reassure that patient will "probably always be ill" and should "learn to live with some pain" | ||
* Avoid unnecessary tests and procedures — may encourage somatization | *Avoid unnecessary tests and procedures — may encourage somatization | ||
* Focus on modification of illness behavior and improved functional status | *Focus on modification of illness behavior and improved functional status | ||
** Decreased frequency and urgency of medical use | **Decreased frequency and urgency of medical use | ||
** Avoidance of expensive and hazardous procedures | **Avoidance of expensive and hazardous procedures | ||
** Improved work or school performance | **Improved work or school performance | ||
** More social activities | **More social activities | ||
** Better personal relationships | **Better personal relationships | ||
==Disposition== | ==Disposition== | ||
* Provide appropriate psychiatric referrals. | *Provide appropriate psychiatric referrals. | ||
* Discharge with education and instructions. | *Discharge with education and instructions. | ||
** There are no alarming findings | **There are no alarming findings | ||
** No further testing or medications are indicated | **No further testing or medications are indicated | ||
** Ongoing care and reassessment will be arranged | **Ongoing care and reassessment will be arranged | ||
* Follow up with primary-care physician — becomes gatekeeper for all medical consultation and care. | *Follow up with primary-care physician — becomes gatekeeper for all medical consultation and care. | ||
** Avoid outpatient tests or hospitalization unless indicated by clear objective signs | **Avoid outpatient tests or hospitalization unless indicated by clear objective signs | ||
** Scheduled follow-up on time-contingent basis (every 2-4 weeks) | **Scheduled follow-up on time-contingent basis (every 2-4 weeks) | ||
*** Reduce association between medical contact and necessity for escalation of illness behaviors | ***Reduce association between medical contact and necessity for escalation of illness behaviors | ||
*** Reduce fear of abandonment | ***Reduce fear of abandonment | ||
==See Also== | ==See Also== | ||
Revisión actual - 01:13 24 jul 2017
Background
- Somatic symptoms associated with distress and impairment that cannot be medically explained
- Most common symptom is pain — may be specific, generalized, or nonspecific (eg, fatigue)
- May represent normal bodily sensations (eg, borborygmus)
- May occur concurrently or secondarily to a medical condition
- Typically encountered in primary care and other medical settings
- Less commonly encountered in psychiatric and other mental health settings
Clinical Features
DSM-5 Diagnostic Criteria for Somatic Symptom Disorder[1]
- 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 or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.
- Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Differential Diagnosis
- Medical conditions
- Irritable bowel syndrome
- Fibromyalgia
- Endocrine disorders
- Poisonings
- Porphyria
- Multiple sclerosis
- Systemic lupus erythematosus
- Wilson's disease
- Myasthenia gravis
- Guillain-Barré syndrome
- Uremia
- Psychiatric conditions
Evaluation
- Screen for organic causes of symptoms
- Psychiatric consultation
Management
Reassurance
- May be successful in young patients with no underlying medical or psychiatric illnesses with clear psycho-social stress
- Unlikely to be successful in patients with chronic somatization
- Perceived as denial of sick role
- Desire for acknowledgment and recognition → disappointment when no pathology discovered
- Resistance to recovery because "specter of cure" threatens sick role
- Development of new side effects, allergic reactions, and symptoms
Legitimization of Symptoms
- Listen and attempt to understand patient's experience
- Explain that patient's illness causes many symptoms but does not lead to medical deterioration
- Offer only guarded projections about patient's condition → safeguards sick role → may limit illness behavior
Diagnosis
- Clarify precise meaning of terms to avoid misinterpretation
- Somatic responses and descriptions may be better accepted than purely psychiatric diagnoses
- Hyperventilation, tension headache, muscle tension, muscle strain, muscle spasm, and stress
- Communicating diagnostic uncertainty may be helpful
- "atypical pain", "multiple complaints following injury"
Medications
- Patient with somatic symptom disorder have a high affinity for medications and are reluctant to discontinue drugs, regardless of benefit
- Prioritize lifestyle modification
- Benign remedies may be helpful — lotions, supplements, elastic bandages, and heating pads
- Avoid drugs that cannot be safely continued indefinitely
- Avoid drugs that produce abstinence syndromes or dependence
- Avoid pain medications; if necessary, prescribe to be take on schedule, not "as needed"
- Antidepressants may be beneficial, including tricyclics
Mental Health Consultation
- Patients resist psychiatric evaluation — threatens sick role
- Patients fear abandonment → reassure primary physician will continue caring for them
- Patients may accept treatment as "stress management" or "education" that targets physical symptoms and somatic distress.
Physician Attitudes
- Focus on understanding patient's subjective experience
- Avoid telling patient nothing is wrong or symptoms require no treatment
- Avoid counter-transference when no physiologic explanation can be found
- Attempt to retain compassion
- Don't label as "difficult patient"
Treatment Goals
- Patients lack insight. Do not attempt insight-oriented psychotherapy.
- Do not promise or attempt cure — threatens sick role
- Patient may escalate illness behaviors — new side effects, allergic reactions, and symptoms
- Reassure that patient will "probably always be ill" and should "learn to live with some pain"
- Avoid unnecessary tests and procedures — may encourage somatization
- Focus on modification of illness behavior and improved functional status
- Decreased frequency and urgency of medical use
- Avoidance of expensive and hazardous procedures
- Improved work or school performance
- More social activities
- Better personal relationships
Disposition
- Provide appropriate psychiatric referrals.
- Discharge with education and instructions.
- There are no alarming findings
- No further testing or medications are indicated
- Ongoing care and reassessment will be arranged
- Follow up with primary-care physician — becomes gatekeeper for all medical consultation and care.
- Avoid outpatient tests or hospitalization unless indicated by clear objective signs
- Scheduled follow-up on time-contingent basis (every 2-4 weeks)
- Reduce association between medical contact and necessity for escalation of illness behaviors
- Reduce fear of abandonment
See Also
External Links
References
- ↑ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.