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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