Updated: 8/18/2018

Somatic Symptom and Related Disorders

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  • A 36-year-old female has been visiting her primary care physician very frequently over the past seven months because she is afraid she has an underlying illness. She has been experiencing mild, nonspecific abdominal pain off and on throughout this time. Despite reasssurances by her doctor, as well as a normal abdominal ultrasound and abdominal CT scan, she is still convinced something is being missed. Because of her fear, she has become socially withdrawn and spends much of her time at home researching diseases on the internet.  (Illness anxiety disorder)
Somatic Symptom and Related Disorders

  • Definition
    • physical symptoms that cause mental distress
    • in DSM-V, less of an emphasis on whether or not an underlying medical condition has been ruled out as a cause for the physical symptoms
    • historically called "hysteria" or "somatization"
  • Epidemiology
    • F > M
    • less educated
    • lower socioecononimc status
    • ethnic minorities
  • Types
    • somatic symptom disorder 
      • one or more physical symptoms that cause distress
      • dysfunctional thoughts, feelings, or behaviors associated with the physical symptoms
      • dysfunction is present for at least six months
    • pain disorder
      • chronic pain that causes significant distress or impairment
      • psychological factors appear to influence the experience of the pain
    • conversion disorder
      • neurological impairment involving voluntary motor or sensory function with no primary neurological cause
        • symptoms may include paralysis, blindness, mutism, or seizures
        • cannot refer to sexual dysfunction or pain
      • often following an acute stressor 
      • patient is aware of but indifferent toward symptoms, known as "la belle indifference"
      • more common in adolescents and young adults
    • illness anxiety disorder 
      • fear of having a serious illness
      • mild or absent physical symptoms
      • dysfunctional or maladaptive behaviors associated with health
        • excessive check ups
        • avoidance of certain behaviors associated with the potential illness
      • preoccupation with illness despite medical evaluation and reassurance
      • fear is present for at least six months
    • factitious disorder
      • deliberately faking or manufacturing symptoms in order to obtain sympathy from others and assume the sick role
        • injuries
        • infections
        • hypogylycemia
      • no external benefit, such as worker's compensation, time off from work, etc.
      • often involved with the healthcare industry in some way and has some degree of medical knowledge
      • extreme subtype is "Munchausen syndrome"
        • travels to numerous hospitals and clinics to seek treatment
        • consents to highly invasive procedures
        • M > F
      • Munchausen by proxy is where the caregiver induces symptoms in a child/elder under their care in order to assume the sick role by proxy 
        • This is a form of abuse and should be reported
    • malingering 
      • deliberately faking or exaggering symptoms for an external benefit, such as worker's compensation, time off from work, avoidance of criminal prosecution etc.
      • associated with antisocial personality disorder
    • psychological factors affecting other medical conditions
      • psychological distress or a maladaptive behavior that triggers, exacerbates, or prevents the treatment of a medical condition
 

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Questions (7)
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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(M1.PY.12) A 22-year-old female presents to your clinic for evaluation of "skin problems." She complains of severe acne and "spots" all over her face that have persisted for the last 8 years, despite innumerable creams and lotions. She reports spending several hours every morning using make-up just to go outside. She wishes to learn about cosmetic procedures or surgeries that could solve her problem. While you perceive her concern for her skin to be genuine, upon examination, you note a healthy-appearing, well-nourished female with a normal complexion, minimal acne and sparse freckles on the nasal bridge. You calculate her BMI to be 21. In addition to making a diagnosis, this patient should be screened for which other disorder? Review Topic

QID: 100012
1

Malingering

5%

(1/22)

2

Munchausen's syndrome

45%

(10/22)

3

Anorexia

18%

(4/22)

4

Trichotillomania

0%

(0/22)

5

Major depressive disorder

23%

(5/22)

M1

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(M1.PY.8) A 27-year-old woman presents to your office complaining of right arm numbness and weakness. Her past medical history is unremarkable. Her family history, however, is significant for the unexpected death of both her parents at age 59 in a motor vehicle accident last week. On physical exam, her bicep, brachioradialis, and patellar reflexes are 2+ bilaterally. CNS imaging shows no abnormalities. Which of the following is the most likely diagnosis? Review Topic

QID: 100008
1

Conversion disorder

90%

(19/21)

2

Vitamin B12 deficiency

0%

(0/21)

3

Amyotrophic lateral sclerosis

10%

(2/21)

4

Arnold-Chiari malformation

0%

(0/21)

5

Multiple sclerosis

0%

(0/21)

M1

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