Learn — Anxiety, stress & somatic disorders

4 notes · 12 questions on the topic

Conversion disorder

Conversion disorder, called functional neurological symptom disorder in DSM-5-TR, is a genuine loss or alteration of voluntary motor or sensory function — weakness, abnormal movement, non-epileptic seizures, blindness, aphonia or numbness — that is internally inconsistent and incompatible with any recognised neurological disease. It is not feigned: the symptom is produced without conscious intent, and the diagnosis rests on positive examination signs of inconsistency rather than on excluding everything else and finding nothing.

DSM-5 made two changes worth remembering: an identifiable psychological stressor is no longer required for the diagnosis, and the clinician no longer has to prove the symptom is not feigned; instead there must be positive evidence of incompatibility with neurological disease.
The positive signs are Hoover's sign, in which hip extension is weak on direct testing but returns when the opposite hip is flexed against resistance; give-way or collapsing weakness; entrainment of a tremor to a tapped rhythm; a dragging monoplegic gait; tubular visual fields; and sensory loss that splits exactly at the midline.
In psychogenic non-epileptic seizures the eyes are usually forcibly closed and resist opening, movements are asynchronous with side-to-side head shaking and pelvic thrusting, there is no lateral tongue bite and no incontinence, no post-ictal confusion, and the serum prolactin does not rise.
La belle indifference, apparent unconcern about a dramatic deficit, is unreliable, occurs in organic disease too, and is no longer a diagnostic criterion, so it should not be used either to make or to refute the diagnosis.
Separate the three by intent and by gain: conversion disorder is unconscious production with no external reward; factitious disorder is conscious production for the internal reward of the sick role; malingering is conscious production for an external reward such as money, leave or avoiding a court appearance.
Primary gain is keeping an intolerable conflict out of awareness, and secondary gain is the attention and relief from duty that follow; only the second is visible to the ward.
Treatment is explanation plus rehabilitation: give the diagnosis positively and by name, demonstrate the Hoover sign to the patient, make clear the symptoms are real and potentially reversible, refer for physiotherapy-led rehabilitation for motor symptoms and cognitive behavioural therapy particularly for non-epileptic seizures, and treat comorbid depression or anxiety.
Avoid the two errors that entrench it: repeated investigation and referral, which teach the patient that something has been missed, and telling the patient there is nothing wrong, which they hear as an accusation of lying.
Prognosis is better with acute onset, a clear precipitant, early diagnosis and short duration, and worse when symptoms are long-standing and disability is established.

Phobia — types

A phobia is a persistent, excessive fear of a specific object, activity or situation that is out of all proportion to the actual danger, provokes immediate anxiety on exposure, and drives the person to avoid the trigger or endure it with dread. Insight is typically retained, so the person knows the fear is unreasonable and still cannot switch it off, which separates phobia from delusion, and DSM-5-TR requires the fear and avoidance to last at least six months and to impair daily life.

There are three groups: specific phobia, with animal, natural environment, blood-injection-injury, situational and other subtypes; social anxiety disorder, a fear of scrutiny and negative evaluation, with a performance-only specifier; and agoraphobia, which in DSM-5 became a diagnosis in its own right rather than an addition to panic disorder.
Agoraphobia is diagnosed on fear of at least two of five situations — public transport, open spaces, enclosed places, standing in a queue or crowd, and being outside the home alone — because escape might be difficult or help unavailable if panic came.
The named phobias asked in examinations are acrophobia for heights, claustrophobia for enclosed spaces, agoraphobia for open or public places, zoophobia for animals, arachnophobia for spiders, nyctophobia for darkness, mysophobia for dirt and germs, algophobia for pain, thanatophobia for death, erythrophobia for blushing, xenophobia for strangers, glossophobia for public speaking and trypanophobia for injections.
Blood-injection-injury phobia behaves unlike every other phobia: heart rate and blood pressure rise briefly and then fall, so the patient faints rather than panics, and the specific treatment is applied tension, deliberately tensing the large muscles to raise blood pressure, rather than relaxation alone.
Graded exposure is the treatment of choice for specific phobia: a fear hierarchy is built and worked through while the patient stays relaxed, which is systematic desensitisation, resting on Wolpe's principle of reciprocal inhibition; flooding exposes the patient to the most feared item at once, and modelling lets them watch someone else cope first.
Drugs do not treat specific phobia. Social anxiety disorder responds to cognitive behavioural therapy with an SSRI such as escitalopram, sertraline or paroxetine, or with venlafaxine; propranolol 10 to 40 mg before a performance blunts tremor and palpitations; benzodiazepines are avoided beyond very short-term use because of dependence and because they blunt the very learning that exposure depends on.
Distinguish the neighbours: in specific phobia the anxiety is cued and predictable, in panic disorder the attacks come out of the blue, in social anxiety disorder the fear is of being judged, and in obsessive-compulsive disorder the fear follows an intrusive thought and is relieved by a ritual.
Age at onset differs by type: animal and blood-injection phobias usually begin in childhood, social anxiety disorder in adolescence, and agoraphobia in the twenties and thirties.
Phobic and other anxiety disorders count as mental illness under the Mental Healthcare Act 2017, and the Act requires insurers to provide cover for mental illness on the same basis as physical illness, a right most patients do not know they have.

Somatoform disorder

The old somatoform group has been renamed: DSM-5-TR calls it somatic symptom and related disorders, and its core diagnosis, somatic symptom disorder, requires one or more distressing bodily symptoms together with disproportionate thoughts about their seriousness, persistently high health anxiety, or excessive time and energy devoted to them, usually for more than six months. The important change is that the symptom no longer has to be medically unexplained, so a patient with real diabetes or real angina can also have somatic symptom disorder if the response to it is out of proportion.

Somatic symptom disorder needs at least one distressing somatic symptom plus excessive thoughts, feelings or behaviours about it, with the person persistently symptomatic for typically more than six months.
Illness anxiety disorder replaces most of what used to be called hypochondriasis: preoccupation with having or acquiring a serious illness, with minimal or no somatic symptoms, for at least six months, in either a care-seeking or a care-avoidant form.
The related disorders in the same chapter are conversion disorder or functional neurological symptom disorder, psychological factors affecting other medical conditions, and factitious disorder imposed on self or imposed on another.
ICD-11 replaces the somatoform list with a single diagnosis, bodily distress disorder, graded mild, moderate or severe.
Briquet syndrome is the older name for a picture of many symptoms across several body systems beginning before the age of 30 and commoner in women; it is the historical ancestor of somatic symptom disorder.
Distinguish by intent: in somatic symptom disorder and conversion disorder the symptoms are not produced deliberately, in factitious disorder they are produced deliberately for the internal reward of being a patient, and in malingering they are produced deliberately for an external reward.
Management is a structure, not a drug: one named coordinating clinician, brief regular appointments scheduled by the calendar rather than triggered by symptoms, a short focused examination at each visit, a firm limit on new investigations and referrals, treatment of comorbid depression and anxiety with an SSRI or SNRI, and cognitive behavioural therapy.
Never say the symptoms are imaginary or that nothing is wrong; say that the symptoms are real, that the tests are reassuring, and that the plan is to restore function while the situation is monitored.
The cost of the disorder is not only distress but iatrogenic harm from repeated scans, unnecessary endoscopy and surgery, and opioid prescriptions, which the scheduled-visit model exists to prevent.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder is defined by obsessions, which are recurrent intrusive unwanted thoughts, urges or images that the person recognises as their own and tries to suppress or neutralise, and by compulsions, the repetitive acts or mental rituals performed to reduce the anxiety the obsession causes. The ritual gives brief relief and by doing so strengthens the cycle, and the diagnosis requires the symptoms to take more than an hour a day or to cause marked distress or impairment. DSM-5 moved obsessive-compulsive disorder out of the anxiety disorders into its own chapter of obsessive-compulsive and related disorders.

That chapter contains obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania or hair-pulling disorder, and excoriation or skin-picking disorder; hoarding became a diagnosis in its own right rather than a symptom of obsessive-compulsive disorder.
The common themes are contamination with washing, doubt with checking, symmetry with ordering and counting, and forbidden aggressive, sexual or religious thoughts with mental rituals; a patient distressed by a violent intrusive thought is describing an obsession, not an intention.
The discriminator asked in every examination is ego-dystonic versus ego-syntonic: obsessive-compulsive disorder symptoms are unwanted and distressing to the person, whereas obsessive-compulsive personality disorder is a lifelong style of perfectionism, orderliness, rigidity and control that the person regards as reasonable and does not wish to change.
Insight is a DSM-5-TR specifier, good or fair, poor, or absent with delusional beliefs, so poor insight does not convert obsessive-compulsive disorder into a psychotic illness.
The Yale-Brown Obsessive Compulsive Scale rates ten items to a maximum of 40 and is used both to grade severity and to measure response, with a fall of about a third counted as a response.
Exposure and response prevention, the behavioural core of cognitive behavioural therapy, is first-line treatment: the patient meets the trigger and is supported in not performing the ritual until the anxiety falls on its own.
SSRIs work in obsessive-compulsive disorder at higher doses and over longer trials than in depression — fluoxetine 40 to 80 mg, sertraline 50 to 200 mg or fluvoxamine 100 to 300 mg daily — and a response takes 8 to 12 weeks; clomipramine, a tricyclic, is the most serotonergic option and is effective but brings anticholinergic effects, postural hypotension, cardiac conduction delay and a lowered seizure threshold.
Partial responders are augmented with a low-dose antipsychotic such as risperidone or aripiprazole, and severe refractory illness is considered for neuromodulation in specialist centres.
In a child, abrupt onset of obsessions and tics after a streptococcal throat infection raises the possibility of a post-streptococcal presentation, which is investigated rather than assumed.
Nursing practice is specific: do not abruptly forbid the ritual and do not perform it for the patient. Agree a graded plan, allow the agreed time, acknowledge the anxiety, and never ridicule the behaviour.

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