psychosomatic
Hemianesthesia
Strict half-body split
rofound monocular blindness(Binocular visual fields)
Sufficient vision in "bad eye" precludes plotting normal physiological blind spot in good eye
Profound monocular blindness (Absence of relative afferent pupillary defect)
Swinging flashlight sign (Marcus Gunn)
Sandor Ferenczi (1910)
The concept of conversion hysteria is applied to organs innervated by the autonomic nervous system; e.g., the bleeding of ulcerative colitis may be described as representing a specific psychic fantasy
Tunnel vision (Visual fields)
Changing pattern on multiple examinations
Peter Sifneos, John C. Nemiah (1970):
Elaborated the concept of alexithymia. Developmental arrests in the capacity and the ability to express conflict-related affect result in psychosomatic symptom formation. Concept of "alexithymia" modified later by Stoudemire, who advocated the term "somatothymia" emphasizing cultural influences on use of somatic language and somatic symptom to express affective distress
Psychophysiological
Meyer Friedman (1959
Delirium, dementia
Psychiatric symptoms secondary to a medical conditio
Psychophysiological
Robert Ader (2007):
Intractable sneezing
Short nasal grunts with little or no sneezing on inspiratory phase; little or no aerosolization of secretions: minimal facial expression; eyes open; stops when asleep; abates when alone
Psychoanalytic
Sigmund Freud
Sigmund Freud (1900)
Somatic involvement occurs in conversion hysteria, which is psychogenic in origin-e.g., paralysis of an extremity.
FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER
aka Conversion Disorder
secondary gain
most important to patients with pain disorder
chronic pain acute pain
pain disorder... ____ most frequently associated with depressive disorders _____: more commonly associated with anxiety disorders
astasia-abasia,
wildly ataxic, staggering gait accompanied by gross, irregular, jerky truncal movements and thrashing and waving arm movements
Psychoanalytic
Peter Sifneos, John C. Nemiah (1970
Depression secondary to interferon treatmen
Psychiatric complications of medical conditions and treatments
Anxiety related to chemotherapy, depression related to limb amputation
Psychiatric symptoms as a reaction to medical condition or treatments
Capacity evaluation; evaluation prior to organ transplantation
Psychiatric/Psychosocial assessment
Sigmund Freud (1900)
Psychic energy that is dammed up is discharged through physiological outlets
Somatoform disorders
Psychological factors precipitating medical symptoms
Franz Alexander (1934, 1968)
Psychosomatic symptoms occur only in organs innervated by the autonomic nervous system and have no specific psychic meaning (as does conversion hysteria) but are end results of prolonged physiological states, which are the physiological accompaniments of certain specific unconscious repressed conflicts. Presented first conceptualization of the biopsychosocial model
depressive or anxiety disorder
SSD commonly exists with what disorders?
Harold Wolff (1943):
Attempted to correlate life stress to physiological response, using objective laboratory tests. Physiological change, if prolonged, may lead to structural change. He established the basic research paradigm for the fields of psychoimmunology, psychocardiology, and psychoneuroendocrinology.
Psychoanalytic
Sandor Ferenczi (1910)
Robert Ader (2007):
Beginning in the 1970s, established the basic concepts and the research methods for the field of psychoneuroimmunology
Georg Groddeck (1910):
Clearly organic diseases, such as fever and hemorrhage, are held to have primary psychic meanings; i.e., they are interpreted as conversion symptoms that represent the expression of unconscious fantasies
Recurrence of depressive disorder in setting of cancer treatment (conditions occur independently); schizophrenia in a patient with end-stage renal disease
Co-occurring medical and psychiatric conditions
George Engel (1977):
Coined the term "biopsychosocial" derived from general systems theory and based on conceptual ideas introduced much earlier by Alexander and Meyer
Involuntary movements Tics Blepharospasm Torticollis Opisthotonos S eizures Abnormal gait Falling Astasia-abasia Paralysis Weakness Aphonia
Common Symptoms of Conversion Disorder Motor Symptoms ( reflexes remain normal, electromyography findings are normal)
Anesthesia, especially of extremities Midline anesthesia Blindness Tunnel vision Deafness
Common Symptoms of Conversion Disorder Sensory Deficits
Psychogenic vomiting Pseudocyesis Globus hystericus Swooning or syncope Urinary retention Diarrhea
Common Symptoms of Conversion Disorder Visceral Symptoms
Leon Eisenberg (1995
Contemporary psychiatric research demonstrates that the mind-brain responds to biological and social vectors while being jointly constructed of both. Major brain pathways are specified in the genome; detailed connections are fashioned by, and consequently reflect, socially mediated experience in the world.
Sigmund Freud (1900)
Conversion hysteria always has a primary psychic cause and meaning; i.e., it represents the symbolic substitutive expression of an unconscious conflict.
Thomas Holmes, Richard Rahe (1975)
Correlated the severity and the number of recent stressful life events with the likelihood of disease.
Anesthesia
Sensory loss does not conform to recognized pattern of distribution
Walter Cannon (1927)
Demonstrated the physiological concomitants of some emotions and the important role of the autonomic nervous system in producing those reactions. The concept is based on Pavlovian behavioral experimental designs
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)
Diagnostic Criteria for Somatic Symptom Disorder.. mild vs moderate vs severe?
Karen Horney (1939), James Halliday (1948
Emphasized the influence of the culture in the development of psychosomatic illness. They thought that culture influences the mother, who, in turn, affects the child in her relationship with the child-e.g., nursing, child rearing, anxiety transmission
Aphonia
Essentially normal coughing sound indicates cords are closing
"Touch your index fingers" Severe bilateral blindness
Even blind patients can do this by proprioception
Coma
Eyes stare straight ahead, do not move from side to side Resists opening; gaze preference is away from doctor
Adolph Meyer (1958):
Formulated the psychobiological approach to patient assessment that emphasizes the integrated assessment of developmental, psychological, social, environmental, and biological aspects of the patient's condition. Basic concept of the biopsychosocial model is implicit in his approach.
psychoanalytic
Franz Alexander (1934, 1968
psychoanalytic
Georg Groddeck (1910):
Systems theory
George Engel (1977):
...
Greek: soma for body, psyche for soul
Paralysis, paresis
Hand falls next to face, not on it Pressure noted in examiner's hand under paralyzed leg when attempting straight leg raising Give-away weakness
Psychophysiological
Hans Selye (1945
Psychophysiological
Harold Wolff (1943):
Antidepressants, such as tricyclics and SSRIs, Sedatives and antianxietyagents Amphetamine
, are the most effective pharmacological agents for pain disorder _____ not especially beneficial and are also subject to abuse, misuse, and adverse effects _____has analgesic effects, may benefit some patients, especially when used as an adjunct to SSRIs, but dosages must be monitored carefully
Systems theory
. Zbigniew Lipowski (1970
any age unknown esp affective / anxiety disorders
3 percent of people in a general practice have persistent pain, with at least 1 day per month of activity restriction because of the pain begins at what age? gender ratio? associated with other psych disorders especially?
. Zbigniew Lipowski (1970
: A total approach to psychosomatic disease is necessary. External (ecological, infectious, cultural, environmental), internal (emotional), genetic, somatic, and constitutional factors as well as past and present history are important and should be studied by investigators working in the various fields in which they are trained.
Differential Diagnosis of SSD
AIDS, endocrinopathies, myasthenia gravis, MS, degenerative diseases of the nervous system, systemic lupus erythematosus, and occult neoplastic disorders
Systems theory
Adolph Meyer (1958):
Psychoanalytic
Helen Flanders Dunbar (1936
panic
IAD... can also occur w/ depressive and axiety disorders patients w/ __________disorder may initially complain that they are affected by a dse
pain disorder
IAD... chronic, but the symptoms are limited to complaints of pain
conversion disorder
IAD.... acute, generally transient, and usually involves a symptom rather than a particular disease.
Meyer Friedman (1959
Theory of type A personality as a risk factor for cardiovascular disease. The basic concept was introduced by Helen Flanders Dunbar as early as 1936.
Sociocultural
Thomas Holmes, Richard Rahe (1975)
Sigmund Freud (1900)
It involves organs innervated only by the voluntary neuromuscular or the sensorimotor nervous system.
Sociocultural
Karen Horney (1939), James Halliday (1948
Systems theory
Leon Eisenberg (1995
25-50% 60-100% anergia, anhedonia, decreased libido, insomnia, and irritability
MDD is present in about _____%patients with pain disorder, dysthymicdisorder or depressive disorder symptoms are reported in ____% of the patients most prominent depressive symptoms in patients with pain disorder:_________________________
Syncope
Magnitude of changes in vital signs and venous pooling do not explain continuing symptoms
Neuroleptic malignant syndrome, acute withdrawal from alcohol or other substance
Medical complications of psychiatric conditions or treatment
Hans Selye (1945
Under stress, a general adaptation syndrome develops. Adrenal cortical hormones are responsible for the physiological reaction.
Helen Flanders Dunbar (1936):
Specific conscious personality pictures are associated with specific psychosomatic diseases, an idea similar to Meyer Friedman's 1959 theory of the type A coronary type
somatoform pain disorder, psychogenic pain disorder, idiopathic pain disorder, and atypical pain disorder
Pain Disorder has been called
5% 12%
Pain disorder 6mo prevalence lifetime prevalence
"Unspecified Somatic Symptom Disorder"
Pain disorder is diagnosed as ______________" in DSM-5 or it may be designated as a "specifier" under that heading
"Look at your hand" Severe bilateral blindness
Patient does not look there
Sudden flash of bright light Severe bilateral blindness
Patient flinches
"Wiggle your fingers, I'm just testing coordination" Severe bilateral blindness
Patient may begin to mimic new movements before realizing the slip
seizure symptoms of conversion disorder
Pseudoseizuresare another symptom Tongue-biting, urinary incontinence, and injuries after falling can occur in pseudoseizures Pupillaryand gag reflexes are retained after pseudoseizure, and patients have no postseizure increase in prolactin concentrations
conversion disorder Secondary Gain
Patients accrue tangible advantages and benefits as a result of being sick being excused from obligations and difficult life situations, receiving support and assistance that might not otherwise be forthcoming, and controlling other persons' behavior
Psychophysiological
Walter Cannon (1927)
Astasia-abasia
With suggestion, those who cannot walk may still be able to dance; alteration of sensory and motor findings with suggestion
1. somatic symptom disorder 2. illness anxiety disorder
______________________ is diagnosed when somatic symptoms are present, whereas in___________________, there are few or no somatic symptoms and persons are "primarily concerned with the idea they are ill."
Learning Theory(conversion disorder))
a conversion symptom can be seen as a piece of classically conditioned learned behavior; symptoms of illness, learned in childhood, as a means of coping with an otherwise impossible situation
conversion disorder La Belle Indifference
a patient's inappropriately cavalier attitude toward serious symptoms; that is, the patient seems to be unconcerned about what appears to be a major impairment not pathonognomonic of conversion disorder
conversion disorder
acute and generally transient and usually involves a symptom rather than a particular disease
Psychodynamic SSD
aggressive and hostile wishes toward others are transferred (through repression and displacement) into physical complaints
SOMATIC SYMPTOM DISORDER
also known as hypochondriasis
FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER
an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is PRECEDED BY CONFLICTS OR OTHER STRESSORS
ILLNESS ANXIETY DISORDER
applies to those persons who are preoccupied with being sick or with developing a disease of some kind a variant of somatic symptom disorder (hypochondriasis)
Nerve blocks and surgical ablative procedures
are effective for some patients with pain disorder; but these procedures must be repeated, because the pain returns after 6 to 18 months
alexithymia
being unable to articulate internal feeling states in words, feelings are expressed with the body
Biological Factors (conversion disorder)
brain-imaging studies have found HYPOmetabolism= dominant sphere HYPERmetabolism of the NONdominant hemisphere and have implicated impaired hemispheric communication in the cause of conversion disorder
conversion disorder PRIMARY GAIN
by keeping internal conflicts outside their awareness. symptoms have symbolic value; they represent an unconscious psychological conflict
Biofeedback
can be helpful in the treatment of pain disorder, particularly with migraine pain, myofacial pain, and muscle tension states, such as tension headaches
Psychoanalytic Factors (conversion disorder)
caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom
SOMATIC SYMPTOM DISORDE
characterized by 6 or more months of a general and nondelusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
somatizationdisorder
concern about many symptoms; have more complaints, onset before age 30, more likely to be women
Psychoanalytic Factors (conversion disorder)
conflict is between an instinctual impulse (e.g., aggression or sexuality) and the prohibitions against its expression
W:M = 2:1 to 10:1 late childhood to early adulthood; rare before 10 y/o or after 35 y/o L>R side affectedi n women
conversion disorder women vs men? side more affected? age?
w/ MDD, anxiety disorders, schizophrenia inc rissk in MONOZYGOTIC. not in dizygotic
conversion disorder... commonly associated with?(3) inc. risk in?
children younger than 10y/o MC in rural populations, with little education, with low IQs, in low socioeconomic groups, and military personnel who have been exposed to combat situations
conversion disorder... limited to gait problems or seizures in? most common in?
paralysis, blindness and mutism suicide
conversison disorder most common clinical features? affected px are at risk for?
acute 95% symptom(+) for 6mos or more = less than 50% tremor seizures
course and prognosis of conversion disorder... onset? _% remit spontaneously poor prognostic factors?
displacement, substitution, and repression
defense mechanisms used by patients with pain disorder are ?
4 to 6 percent, but it may be as high as 15 percent men = women onset of symptoms can occur at any age, the disorder mc= 20-30 y/o blacks>whites social position, education level, and marital status=no effect 3 percent of medical students, usually in the first 2 years, but they are generally transient
epidemiology of somatic symptom disorder men vs women? most commonly seen in what age?
Paralysis, paresis Pressure noted in examiner's hand under paralyzed leg when attempting straight leg raising
hoover test
...
illness anxiety disorder social learning model = ssd psychodynamic = ssd
unknown... (4-6 % in a general medical clinic population) OLDER>YOUNGER no evidence
illness anxiety disorder epidemiology... prevalence? age? races/gender/social position/education/....
PSYCHOSOMATIC MEDICINE
increased understanding of the relationship of medical illness to psychiatric illness, and the greater appreciation of mind and body as one
Biological Factors (conversion disorder)
may be caused by an EXCESSIVE CORTICAL AROUSAL that sets off negative feedback loops between the cerebral cortex and the brainstem reticular formation cerebral impairments in verbal communication, memory, vigilance, affective incongruity, and attention
conversion disorder Identification
may unconsciously model their symptoms on those of someone important to them i.e., during pathological grief reaction, bereaved persons commonly have symptoms of the deceased
Optic neuritis
misdiagnosed as conversion disorder blindness
FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER
originally combined with the syndrome known as somatizationdisorder and was referred to as HYSTERIA, CONVERSION reaction, or DISSOCIATIVE reaction
T
patients with illness anxiety disorder usually complain about FEWER symptoms than patients with somatic symptom disorder T/F?
Pain Disorder
presence of, and focus on, pain in one or more body sites and is sufficiently severe to come to clinical attention does not have to judge the pain to be inappropriate or in excess of what would be expected
IAD
too often these patients are dismissed as "chronic complainers" and careful medical examinations are not performed
female
what gender more likely to develop somatization disorder if with conversion disorder
male
what gender? association exists between conversion disorder and ASPD
