Updated: 5/2/2019

Somatic Symptom and Related Disorders

Topic
Review Topic
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Questions
5
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Evidence
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Overview

Somatic Symptom Disorder
  • Snapshot
    • A 27-year-old woman presents to her primary care physician due to headache, chest pain, and food intolerance. These symptoms have been very distressing for her and reports that these symptoms have been present for approximately 8 months. She previously had seen a headache specialist, gastroenterologist, and obtained a number of electrocardiograms in the emergency department. Their respective thorough work-up was negative. On physical exam, the patient appears healthy and is otherwise unremarkable.
  • DSM V criteria
    • ≥ 1 somatic symptom(s) which
      • are distressing to the patient or
      • leads to a significant amount of disruption in the patient's life
    • the patient experiences excessive thoughts, feelings, and behaviors in relation to their somatic symptoms or their health concerns
      • these manifest as ≥ 1 of the following
        • thoughts about the seriousness of their symptoms are disproportionate and persistent
        • anxiety levels about their health or symptoms are persistently elevated
        • concerns for their symptoms or health take excessive time and energy
    • the somatic symptom must be persistent for ≥ 6 months although
      • these symptoms don't have to always be present
  • Treatment 
    • have a single physician as the designated primary caretaker
      • schedule monthly visits and psychotherapy
      • avoid unecessary diagnostic testing unless indicated
Conversion Disorder (Functional Neurologic Symptom Disorder)
  • Snapshot 
    • A 23-year-old woman presents to her physician's office with paralysis of the left arm and paresthesias of the left leg. She reports that her left arm does "not feel part of me." On physical examination, the patient's mood is incongruent with the presence of her symptoms. She is unable to raise the left arm; however, she was able to obtain an object from her purse.
  • DSM V criteria 
    • ≥ 1 symptom(s) of
      • altered sensory function or
      • altered voluntary motor function
    • clinical findings are not consistent with recognized neurological or medical conditions
    • the patient's symptoms are not better explained by
      • another medical condition or
      • medical disorder
    • the patient's symptoms causes
      • significant distress or
      • impairment in functioning or
      • a need for medical evaluation
  • Treatment
    • patient education and developing a therapeutic alliance (first-line) 
    • cognitive behavioral therapy (CBT)
      • in patients who do not respond to first-line treatment
Illness Anxiety Disorder (Hypochondriasis)
  • Snapshot
    • A 21-year-old man presents to his physician's office with concerns of having heart disease. He says that he has been concerned about having a heart attack for the past 7 months. He constantly checks his pulse and reads about symptoms associated with heart disease on a daily basis. He reports that his worry is causing him a great deal of stress and concern. Medical history is unremarkable. Family history is significant for a myocardial infarction in his father, who is currently living without significant morbidity. Physical examination is normal.
  • DSM V criteria
    • patient's are worried about having or developing a serious illness and
      • this preocuppation is present for at least 6 months and
        • is not better explained by another mental disorder (e.g., obsessive-compulsive disorder and somatic symptom disorder)
    • patient's can have an excessive or disproportionate preoccupation of developing a medical condition if
      • another medical condition is present or
      • if they are at high risk (e.g., strong family history of heart disease)
    • somatic symptoms are typically not present
    • an associated high level of anxiety about their health
    • the patient performs excessive health-related behaviors (e.g., checking their body for the presence of an illness) or
      • the patient may develop maladaptive avoidance patterns (e.g., avoiding doctor appointments)
  • Treatment
    • the goal is to improve coping skills while never dismissing their fears
      • caregivers should closely follow their patients and develop a therapeutic alliance
    • CBT
Body Dysmorphic Disorder
  • Snapshot
    • A 22-year-old woman presents to her primary care physician requesting a referral to see a plastic surgeon. She states that her nose appears that of a witch due to its asymmetry and width. She spends hours looking at the mirror daily and constantly compares her nose to other students on campus. She puts a considerable amount of make-up and wears sunglasses in an attempt to improve her nose's appearance. She has also withdrawn from her social groups at school. Her facial features has caused her to feel depressed and anxious. On physical examination, her nose is symmetric and appears normal.
  • DSM V criteria
    • the patient becomes preoccupied with
      • at least one physical nonexistent defect or
      • slight physical defect
    • repetitive behaviors or mental acts at some point during the illness course
      • repetitive behaviors include
        • mirror checking
        • skin picking
        • excessive grooming
      • mental acts include
        • comparing self appearances to others
    • appearance concerns can result in
      • distress or psychosocial impairment
    • preoccupations with appearance is not better explained by an eating disorder
  • Treatment
    • pharmacologic
      • selective serotonin reuptake inhibitors (SSRIs) (first-line) 
        • can be used in mild, moderate, and severe cases
          • in severe cases it is typically combined with CBT
    • psychotherapy
      • cognitive behavioral therapy
        • can be used in mild, moderate, and severe cases
          • in severe cases it is typically combined with SSRIs
Factitious Disorder
  • Snapshot
    • A 22-year-old woman is brought to the emergency department after fainting and subsequently having a seizure in the parking lot of the hospital. The patient was identified to be a nursing student and a syringe was found on her person. Point of care testing for glucose shows hypoglycemia. Laboratory testing is obtained and is significant for an insulin to c-peptide ratio that is > 1. (Factitious disorder imposed on self)
  • DSM V criteria
    • factitious disorder imposed on self (Munchausen syndrome)
      • the patient falsifies physical or psychological symptoms or induces injury or disease to themselves 
        • when in another person (e.g., a child) it is termed factitious disorder imposed on another (Munchausen syndrome by proxy) 
      • the patient's deceptive behavior occurs in the absence of external rewards
      • this disorder is not better explained by another mental disorder (e.g., delusional disorder)
  • Treatment
    • no specific therapy
    • in factitious disorder imposed on another (e.g., in a child)
      • children must be removed by child protective services 
 

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Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.PY.4689) A 35-year-old female is brought to the emergency department after being found unconscious. The patient is found to have a blood glucose level of 35 mg/dL. Hgb A1c was found to be 5.1%. C-peptide level was found to be decreased. The patient returned to her baseline after glucose replacement. She states that she has never had an episode like this before. She has no significant past medical history but reports a family history of diabetes in her mother. She states that she has been undergoing a difficult divorce over the past few months. What is the likely cause of this patient's condition? Review Topic

QID: 107522
1

Insulinoma

50%

(2/4)

2

Factitious disorder

0%

(0/4)

3

Alimentary hypogylcemia

25%

(1/4)

4

Hypothyroidism

0%

(0/4)

5

Somatization disorder

25%

(1/4)

M2

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SUBMIT RESPONSE 2

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(M2.PY.78) A 32-year-old woman comes in to see her physician because she has had undiagnosed abdominal pain for the past 3 and a half years. Her pain is not related to meals and does not correspond to a particular time of day, although she does report nausea and bloating. In the past two years she has had two endoscopies, a colonoscopy, and an exploratory laproscopy - without any results. She is very concerned because her mother has a history of colon cancer. The patient has been unable to work or maintain a social life because she's constantly worrying about her condition. What is this patient's most likely diagnosis? Review Topic

QID: 106886
1

Somatic symptom disorder

50%

(15/30)

2

Functional neurologic symptom disorder

0%

(0/30)

3

Hypochondriasis

43%

(13/30)

4

Factitious disorder

3%

(1/30)

5

Body dysmorphic disorder

0%

(0/30)

M2

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