somatic manifestationsforpsychiatryresidentrs

Somatic Manifestations of Psychiatric Disorders

Virtually all psychiatric disorders are characterized by disturbances in at least

some physiological functions

As physicians, when should we look for?

Features clearly indicating psychic etiology

Features not clearly explained by organic:

Process of exclusion

Careful exclusion of malignancy

meticulous search for focus

Common Somatic Symptoms:

1. Autonomic disturbances

2. Motor tension

3. Hyperarousal

4. Sleep disturbances

5. Appetite and weight disturbances

6. Energy disturbances

7. Disturbances in sexual drive

Psychiatric Disorders Presenting with Somatic Symptoms….

1. Organic brain syndromes

2. Schizophrenia & other psychotic disorders

3. Mood disorders

4. Anxiety disorders

5. Somatoform disorders

6. Personality disorders

7. Adjustment disorder

Psychiatric Disorders Presenting with Somatic Symptoms

8. Substance-related disorders

9. Factitious disorder

10. Eating disorders

11. Primary sleep disorders

12. Impulse control disorders not elsewhere

classified

13. Sexual and gender identity disorders

Mood Disorders

a. Major depressive disorder

b. Dysthymic disorder

c. Bipolar disorder

d. Cyclothymic disorder

Major Depressive Disorder

Diagnostic criteria:1. At least 1 major depressive episode

2.The episode is not superimposed on schizophrenia, nor

better accounted for by schizo-affective or other

schizophreniform disorders

3.There has never been a manic or hypomanic episode

Criteria for Major Depressive Episode….

A. Presence of at least 5 of 9 symptoms during same 2-

wk period leading to change in the level of functioning

(either 1 or 2 must be present):

1.Depressed mood most of the day, nearly every day

2.Markedly diminished interest or pleasure in almost

all activities most of the day, nearly every day

1. Feeling of worthlessness, excessive/or

inappropriate guilt

4.Insomnia or hypersomnia nearly everyday

Criteria for Major Depressive Episode

5. Psychomotor agitation or retardation nearly everyday

6. Fatigue or loss of energy nearly everyday

7. Significant weight loss in the absence of dieting or medical

illness or gain of >5% weight in one month

8. Diminished ability to think or concentrate

9. Recurrent thoughts of death, suicidal ideas/attempt

B. Not due to substance, medication, medical illness

(hypothyroidism, hepatic encephalopathy, etc.), bereavement

Dysthymic Disorder: Diagnostic Criteria…

1. Depressed mood for most of the day, for more days than not, for

at least two years (one year for adolescents)

2. Two or more of

a) Poor appetite or overeating

b) Insomnia or hypersomnia

c) Low energy or fatigue

d) Low self-esteem

e) Poor concentration or difficulty in making decisions

f) Feeling of hopelessness

Dysthymic Disorder: Diagnostic Criteria

3.No remission for continuous two months

4.No major depressive episode

5.No manic episode

6.No other chronic psychotic disorder

7.Not related to substance misuse

8.The symptoms cause clinically significant distress or impairment of social, occupational, or other areas of functioning

Anorexia, Wt Loss -- ? Malignancy

Focal symptoms:

Cough, alteration of bowel habit, voice change

Pain anywhere in body

Bleeding from any site

GE: Anemia, lymphadenopathy, thyroid nodule, SC nodules, changed moles, clubbing, koilonychia, breast lump

Pleural effusion, collapse, consolidation, mass lesion

Abdomen: organomegaly, lump, testicular enlargement

Cerebellar signs, neuropathy, myopathy

Anorexia, Wt Loss – Lab Tests

Urine RE,

Hb%, ESR, CBC

S. Creatinine

CXR-PA view

Abdominal USG

UGI endoscopy

Other imaging and -scopies depending on focal SS

Anxiety Disorders1. Generalized anxiety disorder

2. Obsessive-compulsive disorder

3. Stress disorders• Acute

• Post-traumatic

4. Panic disorders

5. Anxiety disorder due to medical illness

6. Agoraphobia without panic disorder

7. Specific phobias

8. Social phobia

Somatic Manifestations of Anxiety Disorders

Autonomic hyper-reactivity

Motor tension

Hyper-arousal

Autonomic Hyperreactivity

Shortness of breath, palpitation

Sweating

Dizziness

Hot and cold flushes

Frequent voiding

Nausea, heartburn, belching, flatulence,

frequent loose stools

Motor Tension

Shakiness

Inability to relax

Restlessness

Fatigue

Back & neck pain

Headache, pressure or tension type

Hyperarousal

Irritability or outbursts of anger

Difficulty concentrating

Difficulty in falling or staying asleep

Hyper-vigilance

Exaggerated startle response

Generalized Anxiety Disorder

The core feature of GAD is the

presence of excessive worry about

minor day-to-day problems

Posttraumatic Stress DisorderDiagnostic criteria:

1. History of exposure to a traumatic event in which both of the following components were present:

a) The person experienced, witnessed, or was confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others

b) The person’s response involved intense fear, helplessness, or horror

2. The traumatic event is persistently re-experienced in the form of recollection, including thoughts, images and perceptions, dream, psychological distress or physiological reactivity upon exposure to cues that symbolize or resemble one aspect of the event

Posttraumatic Stress DisorderDiagnostic criteria

4. Persistent avoidance of the trauma-associated stimuli,

including thoughts, conversations, activities, places that

symbolize or resemble some aspects of the trauma

5. Persistent hyper-arousal, not present before trauma:

6. Duration of the disturbance is more than one month

7. The symptoms cause clinically significant distress or

impairment of social, occupational, or other areas of

functioning

Panic Disorder:

Recurrent unexpected panic attacks in the absence of other

primary psychopathology

Criteria for Panic attack:

A discrete period of intense fear or discomfort, in which at

least four of 13 symptoms develop abruptly and reached a

peak within 10 minutes

<4 of the above features may develop over >10 minutes,

may be milder and more persistent, reduces specificity

Symptoms in PA….

1. Palpitations

2. Sweating

3. Trembling or shaking

4. Sensation of shortness of breath

5. Feeling of choking

6. Chest pain or discomfort

Symptoms in PA

7. Nausea or abdominal distress

8. Dizziness, faint

9. Paresthesias (numbness or tingling sensations)

10. Chills or sensations of warmth

11. Derealization or depersonalization

12. Fear of losing control or going crazy

13. Fear of dying

Differential diagnosis:Panic Disorder

1. Thyrotoxicosis

2. Bronchial asthma

3. IHD, LVF, PSVT

4. PUD, GERD

5. AVH, CRF

6. Neuropathies

7. Vestibulopathies

8. Syncope, presyncope

9. Hypoglycemia

10. Pheochromocytoma

11. Other anxiety disorders*

12. Somatoform disorders*

13. Adjustment disorders*

Patterns of Presentation

Persistent GAD

OCD

Phobic disorders

Episodic Panic disorders and panic attacks

Stress disorders

Episodic Autonomic Dysfunction

Hypoglycemia

Pheochromocytoma

PSVT

Presyncope

Recurrent vestibulopathies

Carcinoid syndromes (parasympathetic)

Climacteric hot flushes

Panic attacks

Stress disorders

Somatoform Disorders Conversion disorder

Pain disorder: Associated with psychological factors

both psychological and medical illnesses

Hypochondriasis

Body dysmorphic disorder

Somatization disorder

Conversion Disorder:Common Conversion Symptoms…..

Involuntary movements, including convulsions

Dyspnea, hyperventilation

Abnormal gait

Astasia-abasia

Paralysis, weakness

Anesthesia

Common Conversion Symptoms

Aphonia

Blindness

Deafness

Vomiting, globus hystericus

Pseudocyesis

Dizziness

Diarrhea

Hypochondriasis: Diagnostic criteria

1. Preoccupation with fears of having, or the idea that one has, a serious disease based on person’s misinterpretation of bodily symptoms

2. The preoccupation persists despite appropriate medical evaluation and reassurance

3. The preoccupation causes clinically significant distress or impairment of social, occupational, or other areas of functioning

4. The duration of the disturbance is at least six months

Pain Disorder: Diagnostic criteria

1. Pain in >1 sites is predominant focus of presentation & is of severity sufficient to warrant attention

2. Causes significant distress or impairment of social, occupational, or other areas of functioning

3. Psychological factors are have important role in onset, severity, exacerbation & maintenance of pain

4. Not feigned

5. Not better accounted for by another mental disorder

Body Dysmorphic Disorder:Diagnostic criteria

Preoccupation é imagined defect in appearance

If a slight physical anomaly is present, the person’s concern is markedly excessive

Causes significant distress or impairment of social, occupational, or other functioning

Not better accounted for by another mental disorder

Factitious DisorderDiagnostic criteria:

Intentional production or feigning of physical or

psychological signs or symptoms

The motivation for the behavior is to assume the

sick role

Incentives, as in malingering, are absent:

economic gain

avoiding legal responsibility

improving physical well being

Primary Sleep Disordersa) Dyssomnias

I) Primary insomnia

II) Primary hypersomnia

III) Narcolepsy

IV) Breathing-related sleep disorders

V) Cicardian rhythm sleep disorderb) Parasomnias

I) Nightmare disorder

II) Sleep terror disorder

III) Sleepwalking disorder

Non-Psychiatric Causes of Persistent Sleepiness….

Night-time seep disturbance Inadequate time in bed Extraneous sleep disturbance (children) Shifting duty Excessive caffeine intake Physical illnesses

AS, RA Asthma Heart failure

Non-Psychiatric Causes of Persistent Sleepiness

Sleep disruption SAHS PLMD

With normal night sleep Narcolepsy Infarcts or tumors in hypothalamus or upper

brain stem Drugs

Disorders with Somatic Manifestations not Elaborated

1. Sexual and gender identity disorders

a) Sexual dysfunction

I) Sexual desire disorders

II) Sexual arousal disorders

III) Orgasmic disorder

IV) Sexual pain disorders

V) Sexual dysfunction due to medical illnessb) Paraphilias

c) Gender identity disorders2. Eating disorders

a) Anorexia nervosa

b) Bulimia nervosa

DizzinessA sense of unsteadiness of stance or gait

Vertigo

Pre-syncope

Dysequilibrium

Nonspecific dizziness

Vertigo

Sense of being hurled to the ground, or

of rotation of self or environment, usually complete

Aggravated by eye opening and head movement

Relieved by eye closure and keeping the head steady

Duration - a few seconds to days

Accompanying feature - vomiting, tinnitus

Examination finding - nystagmus

Pre-syncope

Sense of unsteadiness, accompanied by blackout

duration is a few seconds

Accompanied by diaphoresis and roaring in ears

Sometimes followed by loss of consciousness

regained immediately after resulting recumbency

Pallor witnessed

Dysequilibrium

Loss of balance without an abnormal sensation in the head

Usually occurs during walking

Disappears as soon as the patient sits down

Usually cerebellar or sensory Sometimes psychogenic, e.g., astasia-abasia

Nonspecific dizziness

A vague sense of lightheadedness

Often psychogenic

Don’t forget

Anemia

Drugs

Inadequately described dizziness syndromes

Causes of Generalized Aches Rheumatological

Articular

Rheumatoid arthritis

Spondyloarthropathies

Generalized

osteoarthritis

SLE

Vasculitis

Non-articular

Fibromyalgia syndrome

Chronic fatigue syndrome

Polymyositis/DM

Polymyalgia rheumatica

Eosinophilia-myalgia

syndrome

Causes of Generalized Aches Non-rheumatological

Endocrine & Metabolic

Hypothyroidism

Hyperthyroidism

Hyperparathyroidism

Osteomalacia

Chronic Renal Failure

Miscellaneous

Multiple myeloma

Acute leukemias

Disseminated malignancies

Psychogenic rheumatism

Fibromyalgia Anxiety, stress, depression Other functional features: IBS, tension

headache, spasmodic dysmenorrhea Pain is periarticular Lack of objective evidences of

inflammatory arthritis11/18 tender points

Criteria For Fibromyalgia

Widespread pain for three months or longer

Presence of 11 tender points among 18 specified sites

Chronic Breathlessness: Causes

Chronic asthma

COPD

Chronic LHF

Angina equivalent

ILD

Obesity

Anemia

Severe kyphoscoliosis

Psychogenic breathlessness

Psychogenic Breathlessness

Inability to take a deep breath

Occurs at rest and relieved by exercise

Provoked by stressful situations

Does not disturb sleep

Frequent sighing breaths at rest

Short breath-holding time in the absence of

respiratory disease

Inconsistent spirometry results

Acute Breathlessness

Acute severe asthma

Acute exacerbation of COPD

Acute pulmonary edema

Pneumothorax

Pneumonia

ARDS

Inhaled foreign body

Laryngeal edema

Hyperventilation syndrome

Hyperventilation Syndrome Usually young women

Doesn’t occur during sleep

No evidence of cardiac or respiratory disease

Accompanying symptoms:

Light headedness

Central chest discomfort

Carpopedal and peri-oral paresthesias/spasm

Induction of symptoms by submaximal hyperventilation

High scores on Nijmegen questionnaire

ABG: normal PO2, low PCO2, alkalosis

Dyspepsia

Peptic ulcer disease

Non-ulcer dyspepsia

GERD

Neoplasms: gastric

Dyspepsia: Alarm Signs

Weight loss

Vomiting

UGI bleeding

Dysphagia

Anemia

Virchow’s LN

Palpable abdominal mass

Red Flags in Neck Pain

Age >60

Constant progressive, not relieved by rest

Intractable midnight pain

Anorexia, fever, weight loss

Past history of carcinoma, TB

Plantar extensor/hyper-reflexia

Non-red-Flag Organic clues in Neck Pain

Worst in morning, relieved by activity

Aggravated by coughing

Neuro-deficit in upper limbs

TTH vs. ICSOL

TTH ICSOL

Character Pressing, band-like

Dull

Site Occipital Anywhere, later diffuse

Diurnal, worst In afternoon On waking

Aggravation by bending, straining

No Yes

Relief by good sleep, massage

Yes No

Epileptic Seizures vs. Psychogenic Non-epileptic Seizures

Epilepsy PNES

Duration <1-2 minutes >2 minutes

Eyes open during event Closed, forced eye closure

Motor activity Stereotyped

Synchronized

Variable, forward pelvic thrusting

Vocalization Uncommon May occur

Epileptic Seizures vs. Psychogenic Non-epileptic Seizures

Epilepsy PNES

Incontinence Common Rare

Autonomic signs Cyanosis,tachycardia

Rare

Postictal symptoms

confused, drowsy, Headache

rapidly awaken and reorient

Central Sensitization Syndromes

FBDs: IBS FM TTH, migraine Spasmodic dysmenorrhea, chronic pelvic

pain, PMDD RLS Dysuria, OAB TMJ dysfunction

Psychiatric Accompaniments of Organic Disorders

Anxiety disorders associated with medical

illness

Major depressive disorder

Adjustment disorders

Delirium

Dementia