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Financial Disclosures Focus on somatic none symptom and related - - PowerPoint PPT Presentation

Aug 16, 2023 12 likes •182 views

Relevant Psychiatry for the Neurologist Financial Disclosures Focus on somatic none symptom and related disorders, plus catatonia Descartes Li, M.D. Clinical Professor University of California, San Francisco descartes.li@ucsf.edu

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Relevant Psychiatry for the Neurologist

Descartes Li, M.D. Clinical Professor University of California, San Francisco descartes.li@ucsf.edu

Focus on somatic symptom and related disorders, plus catatonia

https://commons.wikimedia.org/wiki/File:E mil_Kraepelin_1926.jpg

Financial Disclosures

none

Outline

  • Illness Anxiety Disorder
  • Conversion Disorder

– (Functional Neurological Symptom disorder)

  • Factitious Disorder
  • Catatonia

Outline

  • Illness Anxiety Disorder
  • Conversion Disorder

– (Functional Neurological Symptom disorder)

  • Factitious Disorder
  • Catatonia
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Case Vignette

41yo man with recurrent worries that he has a brain tumor. Denies any other symptoms. Repeated almost weekly visits to various physicians, numerous brain MRI scans.

https://commons.wikimedia.org/wiki/File:W

  • ody_Allen_(2006).jpeg

Case Vignette

https://youtu.be/N4BSJ7YGClE (4min)

DSM-5 Criteria for Illness Anxiety Disorder

  • A. Preoccupation with having or acquiring a

serious illness.

  • B. Somatic symptoms are not present or are only

mild

  • C. High level of anxiety about health, and easily

alarmed about personal health status.

  • D. Excessive health-related behaviors or

maladaptive avoidance

  • E. at least 6 months
  • F. Not better explained by another disorder.

Formerly known as

hypochondriasis

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Behavior Perspective

Behavior Choice Consequences

Rumination increased likelihood Consequent beh  worsened symptoms

What is the difference between somatic symptom disorder and illness anxiety disorder?

  • Both may present with anxiety
  • Illness anxiety disorder with no symptoms (or
  • nly mild), and fears developing an illness
  • Somatic symptom disorder often has a medical

condition with symptoms, but the reaction to these symptoms is maladaptive

[Somatic Symptom Disorder]

  • A. Somatic Symptoms: One or more somatic

symptoms that are distressing and/or result in significant disruption in daily life.

  • B. One or more of: Excessive thoughts, feelings,

and/or behaviors related to these somatic symptoms or associated health concerns: 1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms (thoughts) 2) Persistently high level of anxiety about health or symptoms (feelings) 3) Excessive time and energy devoted to these symptoms or health concern (behaviors)

  • C. Chronicity: Although any one symptom may not be

continuously present, the state of being symptomatic is persistent and lasts > 6 months.

Questions?

Keep in mind

  • Get a careful history, including pt’s perspective.
  • Prior responses, and consequences.
  • Consider the diagnosis in individuals with multiple

complaints, such as pain, fatigue, or gastrointestinal problems.

  • Individuals often have both a diagnosed medical

condition and abnormal behaviors and thoughts related to this condition.

  • These individuals are genuinely suffering.
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[Examples of Disease Entities That Overlap with Somatic Symptom and Related Disorders]

Specialty Disease Entity Primary care Chronic fatigue syndrome Fibromyalgia Cardiology Atypical chest pain Gastroenterology Irritable bowel syndrome Urology Interstitial cystitis Immunology Multiple chemical sensitivities ENT Temporomandibular joint syndrome Neurology Psychogenic non-epileptic seizures (Conversion disorder) Can be conceptualized as “contested illnesses”

See Dumit 2006. Illnesses you have to fight to get: Facts as forces in uncertain, emergent illnesses. Social Science & Medicine 62 (2006) 577–590

Key rule outs for somatic symptom disorder and related disorders

  • 1. Psychosis
  • 2. Anxiety disorders, especially OCD
  • 3. Cultural syndromes
  • 4. Factitious disorders*

Each has a different management approach. *separate section on factitious disorders

  • 1. Psychosis

– Work with psychiatrist to manage delusions – If psychosis with poor insight, recommend: I

Am Not Sick, I Don't Need Help: How To Help Someone With Mental Illness Accept Treatment, by Xavier Amador

– Consider diagnoses besides schizophrenia

  • 2. Obsessive Compulsive

Disorder

– If OCD is diagnosed, treat using SSRIs/clomipramine and Exposure- response prevention

For OCD with disease obsession, what would the exposure and response prevention look like?

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  • bsessions

compulsions Decreased anxiety Increased anxiety exposure response prevention desensitization

Exposure-Response Prevention

  • 3. Cultural

syndromes

– May overlap with “contested illnesses” (eg, Morgellon’s) – Need to understand specifics of each syndrome

Management of Chronic Major Somatization*

1) Care Rather Than Cure Don’t try to eliminate symptoms completely Focus on coping and functioning as goals of treatment 2) Diagnostic and Therapeutic Conservatism Review old records before ordering tests Respond to requests carefully

(remember these pts often have medical conditions)

Benign remedies

(Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9)

Management of Chronic Major Somatization*

3) Validation of Distress Don’t refute or negate symptoms Patient-physician relationship not predicated on symptoms Focus on social history Regular visits (not prn)

– consider scheduled telephone contacts

(Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9)

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Management of Chronic Major Somatization*

4) Providing a Diagnosis Emphasize dysfunction rather than pathology Describe amplification process provide specific example, if appropriate Cautious reassurance, dispel: “Every symptom must have an explanation” Introduce stress model of disease, if appropriate 5) Mental Health Consultation To diagnose psychiatric comorbidity For recommendations about pharmacotherapy For cognitive-behavioral therapy to improve coping or psychotherapy

(Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9)

Outline

  • Illness Anxiety Disorder
  • Conversion Disorder

– (Functional Neurological Symptom disorder)

  • Factitious Disorder
  • Catatonia

Case Vignette

16yo girl with new onset tics

What Happened to the Girls in Le Roy?

http://www.nytimes.com/2012/03/11/magazine/teenage-girls- twitching-le-roy.html

https://youtu.be/cCED0PQqXZg

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http://www.nytimes.com/2012/03/11/m agazine/teenage-girls-twitching-le- roy.html

What Happened to the Girls in Le Roy? DSM-5 Criteria for Conversion Disorder

(Functional Neurological Symptom Disorder)

  • A. One or more symptoms of altered voluntary

motor or sensory function.

  • B. Incompatibility between the symptom and

recognized neurological or medical conditions.

  • C. Is not better explained by another medical or

mental disorder.

  • D. Causes clinically significant distress or impairment

in social, occupational, or other important areas of functioning or warrants medical evaluation.

Specify symptom type: abnormal movement, seizures, speech, sensory loss, etc. Specify if: acute or persistent Specify if: with or without psychological stressor (specify stressor)

History of conversion disorder

DSM-II: Hysterical neurosis

History of the DSM DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994) DSM-5 (2013) Hysteria  psychosomatic  somatoform the DSM-II, hysterical neurosis

Hystero-epilepsy

Jean-Martin Charcot 1825-1893

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Other examples of conversion disorder

  • psychogenic non-epileptic seizures

(PNES) aka pseudoseizures

  • Sudden paralysis of right upper

extremity

  • Sudden onset of unilateral hearing loss
  • Also hysterical blindness, incontinence

Characteristics of PNES

1. triggered by stress 2. no incontinence 3. no post-ictal confusion 4. speaking during the episode 5. >10minutes 6. always witnessed 7. resolution with psychosocial interventions

Risk factors How do you treat Conversion disorder?

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http://www.neurosymptoms.org/ Conversion disorder management

https://vimeo.com/ 136982979

The Fringe 2015: Hidden World of Functional Disorders

conversion disorder management

  • Can be very useful to be

straightforward and educational

  • Attitude and word choice may be key
  • Reassure that condition usually

resolves with treatment (PT, stress reduction)

  • However, conversion may overlap

with management of factitious disorder

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Outline

  • Illness Anxiety Disorder
  • Conversion Disorder

– (Functional Neurological Symptom disorder)

  • Factitious Disorder
  • Catatonia

Case Vignette

24-year-old veterinary student with a history of knee osteosarcoma and chemotherapy passed out while on rounds

  • ne morning.

Labs revealed: Hemoglobin of 5.2g/dL, MCV112. She was admitted to the hospital.

The next day, her parents flew in from out of town and found numerous bottles of the patient’s blood in her apartment.

What happened? What is the most likely psychiatric diagnosis?

Factitious disorder*

assessment tips

  • Trace development of symptoms over time

– Symptoms often emerge or change over time (shaping)

  • Look for modeling, rewards, explicit instructions,

medical backgrounds

  • Patients are often immature or dependent, with

limited problem solving skills.

  • He or she may be easily suggestible and

hypnotizable

*These tips also apply to conversion disorder

http://hypnosis.tools/suggestibility-scales.html

Factitious Disorder

Imposed on Self

  • A. Falsification of physical or psychological

signs or symptoms, or induction of injury or disease, associated with identified deception.

  • B. Presents self to others as ill, impaired, or

injured.

  • C. Evident even in the absence of
  • bvious external rewards.
  • D. Not better explained by another

mental disorder Specify: Single episode or Recurrent episodes

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Munchausen’s syndrome

non-DSM term for a severe form of factitious disorder

  • Characterized by recurrent

hospitalization, travelling, and dramatic, untrue, and extremely improbable tales

  • f their past experiences

Is this factitious disorder? (what causes factitious disorder?) What about the 16 other girls? Malingering? Cultural syndrome? Mass hysteria?

Factitious disorder management

Remember:

  • The patient’s need to be consistent can be

the crucial sustaining factor

  • Confrontation is often

dramatically unsuccessful

  • Successful outcome often

depends upon persuasion and countersuggestion

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Factitious disorder management

  • Sometimes ignoring the

symptoms is sufficient

  • Communicate expectation of

resolution

  • Suggest a disease course
  • Offer improvement without

embarrassment

  • Graduated prescriptions: e.g., physical therapy
  • Let go of the need to be right
  • For more complex cases, a team/systems approach is

critical (high level expertise required)

Take Home Points

  • Medical conditions and somatic

symptom and related disorders often co-occur (eg, epilepsy and seizures of non-epileptic

  • rigin)
  • It may be impossible to prove the

diagnosis definitively.

  • Countertransference may be intense,

and may be a clue to the diagnosis

  • A consultation from outside the team

can be essential.

uppgivenhetssyndrom https://www.newyorker.com/magazine/201 7/04/03/the-trauma-of-facing-deportation

The Resignation Syndrome Resignation Syndrome: Catatonia? Culture-Bound?

Sallin K et al Front. Behav. Neurosci., 29 January 2016 | https://doi.org/10.3389/fnbeh.2016.00007 https://www.frontiersin.org/articles/10.3389/fnbeh.2016.00007/full

Not Catatonia!

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Outline

  • Illness Anxiety Disorder
  • Conversion Disorder

– (Functional Neurological Symptom disorder)

  • Factitious Disorder
  • Catatonia

Catatonia

  • “insanity of tension”
  • identified in 1874 by

Karl Kahlbaum

  • 26 cases

– 12 with severe depression – 3 with neurosyphilis – 2 with TB

Weder ND et al. Catatonia: A Review. Annals of Clinical Psychiatry,20:2,97 — 107. DOI: 10.1080/10401230802017092

https://commons.wikimedia.org/wiki/File:Karl _Ludwig_Kahlbaum.JPG

16 behaviors: negativism, staring, grimacing, stereotypy, mannerisms, echophenomena, waxy flexibility

Catatonia

  • Kraepelin assigned catatonia to the

category of dementia praecox

  • Bleuler (1907) designated catatonia

as a marker of schizophrenia

  • 1950s, treatment with antipsychotics

frequently led to fever, hypertension, tachycardia, muscular rigidity  neuroleptic malignant syndrome Diagnoses associated with catatonia

study n Schizoph renia Bpdo Mood d/o Abrams + Taylor 55 7% Huang et al 34 26% 23% 9% Benegal et al 65 26% 23% Lee et al 24 54% 17%

Also, endocrine abnormalities, infections, electrolyte imbalances, epilepsy, strokes (of anterior brain region), withdrawal from benzodiazepines

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Risk factors

  • h/o perinatal infections
  • Prior episodes of catatonia
  • h/o eps from medications
  • Epilepsy
  • Exposure to meds that lower seizure

threshold

  • Long term exposure to

anticholinergic drugs

  • Frontal or basal ganglia diseases

[DSM5 organization of catatonia]

  • Catatonia associated with another

mental disorder (catatonia specifier),

ICD-10 F06.1

  • Catatonic disorder due to another

medical condition, ICD-10 F06.1

  • Unspecified catatonia

No longer only a subtype of schizophrenia

[DSM5 definition of catatonia ICD F06.1]

  • A. The clinical picture is dominated by

three (or more) of the following symptoms:

  • 1. Catalepsy (i.e., passive induction of a posture held against

gravity)

  • 2. Waxy flexibility (i.e., slight and even resistance to

positioning by examiner)

  • 3. Stupor (no psychomotor activity; not actively relating to

environment)

  • 4. Agitation, not influenced by external stimuli
  • 5. Mutism (i.e., no, or very little, verbal response [Note: not

applicable if there is an established aphasia])

[DSM5 definition of catatonia]

Criterion A continued. Underlined symptoms more common

  • 6. Negativism (i.e., opposing or not responding to

instructions or external stimuli)

  • 7. Posturing (i.e., spontaneous and active maintenance of a

posture against gravity)

  • 8. Mannerisms (i.e., odd caricature of normal actions)
  • 9. Stereotypies (i.e., repetitive, abnormally frequent, non-

goal directed movements)

  • 10. Grimacing
  • 11. Echolalia (i.e., mimicking another's speech)
  • 12. Echopraxia (i.e., mimicking another's movements)

Periods of hypokinesis and hyperkinesis may alternate in a predictable fashion

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Video of catatonia

https://www.youtube.com/watch?v=_s1lzxHRO4U (4min)

Differential diagnoses

  • 1. Malignant catatonia
  • 2. Malignant hyperthermia
  • 3. Neuroleptic malignant syndrome
  • 4. Serotonin syndrome
  • 5. Extrapyramidal symptoms
  • 6. Locked in Syndrome
  • 7. Elective mutism
  • 8. Delirious mania
  • 9. Delirium
  • 10. Akinetic mutism

N.B. Bolded conditions may be considered conditions related to catatonia in pathophysiology

[Pathophysiology?]

  • Frontal cortex striatum  pallidum

 thalamus  cortex

  • But Striatum inhibits the pallidum,

which in turn inhibits the thalamus

  • If striatum is damaged or inhibited,

the pallidum will inhibit thalamus in unopposed fashion

  • Ambien inhibits pallidum
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Benzo’s inhibit pallidum Striatum inhibited in catatonia? Red lines are inhibitory Green lines are excitatory

Basal Ganglia

By The original uploader was RobinH at English Wikibooks - Transferred from en.wikibooks to Commons., CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=36970335

https://en.wikipedia.org/wiki/Basal_ganglia

By Created by Andrew Gillies [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons

Benzo’s in catatonia

  • Acute remission rates around 80%
  • Typically respond within minutes to

iv benzodiazepines and 1-2 hours with oral formulations.

  • However, tolerance to

benzodiazepines does occur

  • Chronic catatonia (>3 weeks)

associated with schizophrenia responds less well

ECT in catatonia

  • Not many well-designed studies,

available evidence generally points to a favorable response

  • May directly treat underlying illness

(mania or depression)

  • Lorazepam may be more effective

after ECT is initiated

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[Treatment algorithm]

A trial of lorazepam as an initial step is warranted as it is a safe therapeutic option with a success rate of about 80%.

  • 1. Start with lorazepam iv 1–2 mg challenge with a rating
  • f catatonic signs after the first hour.
  • 2. Then up to 24 mg a day with 6 full days of treatment

followed by the taper to the optimum dose.

  • 3. If the patient failed to respond adequately to lorazepam,

then bilateral ECT treatments is warranted. (consider earlier use of ECT for autonomic instability, hyperthermia or malignant catatonia).

  • 4. If patient responds to ECT within the first few

treatments, at least 6 sessions should be administered.

[Treatment algorithm]

  • 5. If the patient fails to respond to trials of lorazepam and/or

ECT, a trial of memantine, carbamazepine, or topiramate as monotherapy or in combination with lorazepam or ECT should be attempted

  • 6. If the patient responds to medications or ECT, they should

be continued on those medications for 9–12 months or on ECT for 6 months.

Weder ND et al. Catatonia: A Review. Annals of Clinical Psychiatry,20:2,97 — 107. DOI: 10.1080/10401230802017092

Summary

  • Illness Anxiety Disorder
  • Conversion Disorder

– (Functional Neurological Symptom disorder)

  • Factitious Disorder
  • Catatonia

Next topics?

  • Tardive dyskinesia
  • Anxiety disorders
  • Agitation in dementia*
  • Neuropsychiatric syndromes*
  • More on the electroconvulsive

therapy