Health Anxiety, and Illness Related Psychological Distress | Somatic Symptom Disorders | DSM 5 TR

Hello everybody and welcome to this week's CEU class on health anxiety and illness related psychological distress. In the dsm, this is the category of somatic symptom disorders. I'm your host, Dr. Donnellice Snipes. In this presentation you're going to learn about the category of somatic symptom disorders in the DSM 5 TR. We'll explore the diagnostic criteria for the disorders in this category as outlined in the DSM V TR and identify risk factors and co occurring issues as identified in the DSM5TR as well as in clinical research that is from PubMed. All of the disorders in the somatic symptom disorder section are focused mainly on somatic symptoms or illness anxiety. Although in the DSM 5 they tried to more effectively differentiate the disorders, there is still a great deal of overlap and you'll see that when we get in there. Interestingly, the DSM notes that non psychiatric physicians and mental health clinicians found the DSM IV diagnostic criteria difficult to apply, which is why they revised it in the DSM 5 by reducing the number of disorders and subcategories. So in the DSM IV it was even harder to differentiate and differentially diagnose. It's important to remember that many mental disorders initially present with primarily physical or somatic symptoms, and in some cultures that somatic presentation may always predominate. Previous criteria for somatic symptom disorders overemphasized the importance of symptoms being unexplained by a physiological exam. It is noted in the DSM 5TR that it is not appropriate to give an individual a mental disorder diagnosis solely because there is a lack of physiological findings. That is an important note that we need to remember when making these diagnoses. Risk factors for somatic symptom disorders include genetic and biological vulnerabilities that cause differential pain perception. Well, that makes sense. When somebody is more sensitive to pain or less reactive to pain, it can present as different symptoms, neurological disorders or chronic pain issues or somatic symptoms. Trauma is also a risk factor for somatic symptom disorders, if you'll remember from other presentations. Van der Kolk has said repeatedly that a lot of times trauma is remembered in the body. It's remembered as a somatic sensation, not necessarily as an overt memory. Additionally, people who are in situations in which the sick role is reinforced may be more likely to present with somatic illnesses as well as situations in which there is not any reinforcement for mental health presentations of distress. Again, in some cultures and even in some families, mental distress is ignored, minimized pathologized and somatic symptoms or physical symptoms are the only thing that is recognized and considered a valid complaint. So the presentation of mental illness or mental health issues may vary based on culture and family acceptance of mental health symptoms. Differences in cultural expectations and explanations for physical symptoms or somatic symptoms and the differences in the management of symptoms may also be a risk factor or a differentiating factor for diagnosis of somatic symptom disorder. So let's talk about somatic symptom disorder. And it is obviously the primary disorder in this category that is titled somatic symptom disorders. In somatic symptom disorder, the person has to have one or more physical symptoms that result in clinically significant distress. Stress. Okay, that's pretty broad. They must exhibit excessive thoughts, feelings, or behaviors related to the physical symptom. Now, excessive is what differentiates it from, quote, normal or expected anxiety or behaviors. And there is no objective definition of acceptance. Excessive. The excessive thoughts or feelings or behaviors can be characterized by one or more of the a disproportionate persistent thought about the seriousness of the illness. So if somebody has. I have a strong history of cancer in my family, particularly melanoma. So I'm regularly checking my. My freckles and my moles. Now, if I were disproportionately obsessed, you know, oh, this mole looks a little strange, and it suddenly consumed what I was doing, then that might qualify. Persistently high level of anxiety about the symptoms. So if I had a lot of anxiety about the fact that, you know, some of my moles are slightly different colors or whatever, that could also be a symptom. But again, it has to be excessive. And who defines excessive? That's one of the things we're going to talk about. And finally, excessive time and energy is devoted to these symptoms or concerns. So let's switch gears. You know, cancer is something people worry about. Viruses or something people worry about. But menopause, hot flashes, okay, that is a physical symptom that can result in clinically significant distress. If you've ever had hot flashes, you know, it can wake you up in the middle of the night. Hot flashes can be really disruptive to your life. And. And they're real. They. They exist. A lot of times when you have hot flashes, your heart is also racing a little bit. It can increase up to 20 beats a minute. They say a person may spend a lot of time and energy trying to figure out, what can I do to control these hot flashes so I can sleep through the freaking night? And they're looking at different mattresses and different sol, looking at different herbs and consulting different doctors. Is that excessive when the physical symptoms are preventing them from being able to sleep? I'm not saying one way or another. However, I think it's important for us to consider what is the impact the symptom is having on the person and how much is it the symptom itself being functionally disruptive for them? And as a result of that, is the time and energy devoted to the concerns or alleviating the concerns excessive? It may not be. We need to be really, really careful about pathologizing people's desire to have a reasonable quality of life. And finally, for the diagnostic criteria, although any particular symptom may not be continuously present, the person exhibits symptoms continuously for at least six months. So they may have disproportionate or persistent thoughts about the seriousness of a variety of different concerns or persistently high levels of anxiety about a variety of symptoms that they're experiencing. Or they may spend excessive time and energy devoted to a variety of different symptoms. And you know, for those of you who are older, you know, as you get older, you seem to break a little bit more. And there is a. And younger people who are going through growth spurts may have aches and pains and changes that vary over the course of several months. So we do want to consider, you know, what's going on and is this excessive for the person? Somatic symptom disorder can be diagnosed with or without a medical explanation. And I'm going to spend most of the time in this presentation on somatic symptom disorder since it is the primary diagnosis and the one with the most research behind it in this category. But so somatic symptom disorder can develop in somebody after they've had a heart attack. They may be hypervigilant to signs of another heart attack. Well, that kind of makes sense. Now we want to look at, is there concern and is, are there feelings about this fear about having another heart attack? Is it disruptive to their life? And you know, it's really, this is where it kind of starts getting really dicey to differentially diagnose between somatic symptom disorder and anxiety and illness related anxiety. But I digress. Supraventricular tachycardia is another one of those things. It's kind of like when you take your car to the mechanic and there's this sporadic squeak or issue that you're having. The mechanic can't find it. So they said there's nothing wrong. It's, you know, all in your head. SVT is one of those that we're going to talk about that is really difficult a lot of times for doctors to catch because it occurs so sporadically. You can have multiple in a day and then go weeks or months without having one. Supraventricular tachycardia is when your heart rate goes from normal for you to all of a sudden just jumping up to, you know, 170, 180, 200, and it feels like it's going to pound out of your chest and it hurts. So supraventricular tachycardia is one of those that people may be more hypervigilant about after they've had an episode because it's terrifying. But it's also one that is often dismissed by doctors that say, well, if it resets on its own, it's not a big deal. Well, what happens if it doesn't reset on its own? If somebody has had a death of a loved one from fill in the blank, cancer, heart attack, stroke, whatever, then they may become more hypervigilant when they have similar symptoms. I already talked about menopause. That can be something that comes on. It comes on at different ages for different people, but it can cause a variety of physiological symptoms that may be disruptive to the person's life, that they may spend a lot of time trying to figure out how to manage the virus. And I can't say the C word because the YouTube algos would like completely lose their ever loving mind. But getting sick with a virus can be. Can also prompt somatic symptom disorder or health anxiety or I'm sorry, they call it illness anxiety in people. When they start getting a sniffly nose, they start thinking, oh my gosh, I must have this virus. When they have a cough that's sort of quote, unexplained, they may worry about it, especially when that particular disorder, whatever it is, is regularly presented to the people and there are a lot of diffuse symptoms that can characterize it. Then it can become easier for people to develop somatic symptom disorder and become hypervigilant to a lot of those symptoms. Oh, do I have a headache? Oh, wonder what that means. Fibromyalgia. And POTS Fibromyalgia was actually initially identified in 1904, but wasn't recognized by the American College of Rheumatology until 1990. POTS Postural orthostatic tachycardia syndrome was originally identified, I believe in 1984. I had the reference later in the presentation, but there are a lot of doctors that say, still don't believe that it truly exists. Now, interestingly enough, fibromyalgia and POTS both have clinically identifiable symptoms. In fibromyalgia, it's through an MRI and through blood tests and pots, there's a variety of other tests that can identify whether somebody meets criteria. But despite that, for the longest time, fibromyalgia was dismissed as being something that was not a real diagnosis. Now that now we know it is, and you know, POTS is still trying to establish itself despite there being clinical centers of excellence like the one at Vanderbilt that are actively studying chronic fatigue is another one of those syndromes or issues that people can have that has long been pathologized, if you will, and stigmatized because it's what they call a diagnosis of exclusion. There is no test for chronic fatigue. It's just a person who presents with a certain set of symptoms that aren't explained by anything else must have chronic fatigue. Hyperparathyroid. And this one I bring up specifically because I have known a couple of people who've had it and it has gone. They've gone years without it being diagnosed. But people with hyperparathyroid may experience fatigue and depressive like symptoms as well as, quote, according to the Mayo Clinic, frequent complaints of illness with no apparent cause. So this is another one that often probably got pushed off as a mental health issue when in actuality there was an actual dysfunction within the hyperparathyroid gland. Oh my gosh. And both of these people, once they had their hyperparathyroid gland removed, they were asymptomatic. Imagine that. And then I did find another article that was interesting that indicated that PTSD often has a lot of somatic symptoms. Quote Somatic symptoms are ubiquitous, especially are a ubiquitous aspect of the clinical presentation of ptsd. Therefore, we need to recognize that people with PTSD often have somatic symptoms. Now, that's not really highlighted a lot in the diagnostic criteria. So a lot of times people with PTSD and concurrent somatic symptoms or people with depression and concurrent somatic symptoms are given somatic symptom disorder diagnosis in addition to the other. In addition to the other diagnosis because the mind body dualism is still not really well integrated in the DSM. 66% to 75% of people who previously were diagnosed with hypochondriasis. I know, that's like dragging your fingernails down a blackboard to hear it. Are now diagnosed with somatic symptom disorder. The rest are diagnosed with illness, anxiety, hypochondriasis is no longer a diagnosis in the DSM 5 or the DSM 5 TR. A distinct characteristic of people with somatic symptom disorder is not the somatic symptoms per se, but instead the way they present or interpret them. They may have a symptom which is either a normal bodily symptom or a what many people would consider a minor pain or a minor symptom. And they are perceiving it as far more dangerous and intense. Now that can be for a variety of reasons. Part of it could be because of perceptual differences and I really didn't find much on the comorbidity of somatic symptom disorder and other mental health issues that involve sensory differences like autism spectrum disorders or adhd. But I would wonder if there's a higher comorbidity there in those, especially in those that are hypersensitive to sensory stimulation. I'm just hypothesizing, however, the fact that we even say that it's not the symptom that's the problem, it's the way that you're interpreting it often causes invalidation of the person. The doctors often say it's all in your head or you're overreacting. Well, how invalidating is that? How hopeless and helpless do I feel if I've got this chronic symptom that is impairing my quality of life? And my medical providers talk to me like I'm an idiot? You know, that's very invalidating. So a lot of people who receive that reception from their physician often go to the Internet to try to self diagnose and self treat their issues. Anybody who's gone on the Internet to try to self diagnose knows that the information out there varies widely in credibility and it very easily promotes catastrophic perceptions. You know, you can go to just about like on Mayo Clinic or WebMD and look up just about any symptom and under each one of them it will say there's a small chance that it could be cancer. Okay, so then the person that has somatic symptom disorder or health related anxiety, now they have that in their head and it becomes terrifying for them. So a lot of times by invalidating and dismissing patients, doctors are actually increasing the severity of their their anxiety and their hyper vigilance towards symptoms. Well, what does this do aside from create more mental health and dysphoria? It keeps that HPA axis excessively triggered. And we know when that happens that increased cortisol and persistently can lead to increased inflammation and can start causing dysfunction and other bodily symptoms. So not only is invalidating patients perceptions, increasing their their mental health issues, it's also probably increasing their physical health issues. Somatic symptom disorder that occurs with other mental health issues often results in more functional impairment and more difficulty in treatment. The more symptoms that are there, the more systems that are probably involved and feeding off of each other. So as one symptom or one condition gets worse, it probably worsens the other conditions. Likewise, when one symptom starts getting better, hopefully it also improves the other symptoms. The more category B symptoms of somatic symptom disorder, that is the more they perseverate on the seriousness of the disorder, the more they have anxiety about having the disorder and the more time and energy they spend trying to address the disorder, likely the more severe the somatic symptom disorder is. People with somatic symptom disorder have a high frequency of medical visits which rarely alleviate their concerns. And it even states in the DSM that a lot of times doctors are very dismissive and invalidating of people's presentation. Additionally, the people may get to a doctor that says, okay, well we can try to treat you with this. If the treatment doesn't work, then the person feels helpless and hopeless. And sometimes the doctor says, well if that was the problem, that treatment should have worked. So that must not be the problem. Ergo it must be all in your head. And not all doctors do this. I do want to emphasize the fact that there are good doctors out there, but unfortunately this happens. My experience and with personally and with friends and family, this happens more often than not. There was a 2015 article that was relatively scathing about the somatic symptom disorder and it said the new DSM 5. This was before the TR Somatic Symptom Disorder over psychologizes chronic pain. It has low sensitivity and specificity and contributes to misdiagnosis and stigma. So think about people with fibromyalgia who up until recently were falling through the cracks. It was, I believe in 2017, maybe 2007. I can't remember right off hand, but very, very recently they recognized that a lot of people with fibromyalgia were not getting diagnosed because the criteria were actually too restrictive. So they changed the criteria. Now all those people that quote, fell through the cracks actually had fibromyalgia and were denied treatment because it was considered, they were considered to have it as a somatic symptom issue or something else, who knows. So I think it's really important that we take people's perceptions of, of Their physical symptoms very, very seriously. We may not understand it, we may not see it, but it's important to recognize how it impacts their quality of life and recognize that we don't know every disorder that exists. Like I said, POTS just recently started being diagnosed, you know, compared to other things and are being identified. Back when I was in high school, you know, to kind of put it into perspective. Associated features of somatic symptom disorder. Catastrophic interpretation of normal bodily sensations. When somebody has a sensation, they think, oh my gosh, this is it. This is the big one. My grandmother when, after my grandfather died, now they had been married for 50 plus years and they had a very traditional marriage where he took care of things, she took care of the house. When he passed on, all of the stuff that he did fell onto her. And it wasn't something that she was used to. So she had high levels of anxiety and occasionally would have a vasovagal response and fall out. And her interpretation of what was going on was. It was the good Lord calling her up to heaven, you know, that was her catastrophic interpretation of the symptoms of the heart palpitations that were going on. And it was important to examine everything that was going on because this was really more a grief and anxiety and anxiety issue for her because she felt overwhelmed with everything that was going on and was perpetually stressed out, not sleeping well. But I digress. Associated features also include a self concept of bodily weakness. They perceive themselves as more frail and more likely to get sick. Intolerance of physical symptoms. A lot of us, I would venture to say that most everyone has awakened at some point and they've had a kink in their neck from sleeping wrong. Or they have back pain and they're not really sure where it came from. They just wake up and it's there. Or they suddenly get this ringing in their ears. And instead of looking at the most likely explanation, did I lift something wrong? Did I sleep wrong? They cannot tolerate that symptom. And they start on this, you know, fast track of catastrophic explanations for what's going on. Negative affect, including a sense of hopelessness and helplessness. And quote, demoralization straight from the DSM 5TR. The person feels hopeless and helpless. That's a primary description of a depressive symptom. And they may feel demoralized. They may feel like they're not believed. They may feel like nobody's there to help them. Unsupported because they are regularly being invalidated. Typically, people with somatic symptom disorders present in a medical setting because they're concerned about, guess what, a physical symptom. You don't go to a psychologist if you've got a physical symptom. Reassurance by medical professionals and attempts to refocus the person's concerns proves futile. And this is important, but it is not. Remember, it is not a diagnostic feature. It's just associated the reassurance. The person may have gone to other doctors before and been reassured that hey, it's no big deal, you don't need to worry about it. But they can't explain what's causing it or the symptoms getting worse or the symptom is causing them clinically significant impairment in functioning. Yet they can't get any validation from profession from their professionals to date. So going to the current professional, they may say, well, you know, I only have a mild belief that this person can be helpful, but I'll try again anyway. And attempts to refocus the person's concerns prove futile. When you're being told that, okay, yes, you have this symptom, but it's not that big of a deal, you need to turn your attention to, you know, stop it, stop ruminating about it. Instead of focusing on what's causing it, you need to focus on stop ruminating. That can feel extremely invalidating as well. The prevalence according to the DSM 5tr is 7 to 17%. Now, looking online, looking in PubMed, there were actually very few research articles that I found that looked at the prevalence in a in the general population. There were some that looked at the prevalence in medical students, some that looked at the prevalence in very, very specific subgroups. But finding accurate data about the prevalence in the general population was not there except for what is stated in the dsm. So I'm not sure where those numbers came from, but those are the numbers. Still 17%, that's almost one in five. So it's important to recognize that that's a pretty high number. It says that somatic symptom disorders are higher in women. And you know, I tend to take issue with that because of the stigma associated with it. What many women perceive when they hear that is just like when they hear that prevalence of anxiety disorders is higher in women, they hear that the perception is that females may present in ways that are more, to use the old term, hypochondriacal, if that's even a correct conjugation of it. However, there are some interesting things that they don't point out and there are some interesting things to consider in today's day and age with a lot of people that are undergoing gender reassignment procedures. Testosterone seems to be unrelated to pain perception. Okay, so that's interesting. However, estrogens and progesterone seem significantly impact not only pain perception, but also serotonin levels. This is something that is really important for us to recognize for people who are biologically female as well as for people who are transitioning to female because the addition of estrogens and progesterone may impact their, some of their physiological symptoms. Estrogens also directly interact with cardiac function. Okay, well, so let's think about this. When estrogen is high, people tend to have more anxiety symptoms. Heart racing, shallow breathing, clammy hands. High levels of estrogens are associated more with activation of that HPA axis and again, that cardiac function. Heart, heart beating. A lot of people with somatic symptom disorders have symptoms that are related to either pain or heart function. So estrogen alterations may impact the symptoms. Therefore, I think it's important that we make sure that the person has had a physiological workup not only for estrogens, but also to look for imbalances and things like thyroid to assess if there are any underlying thyroid or any underlying hormone conditions that may be contributing to the somatic symptoms that aren't readily apparent. Elevated cyclic estrogens are associated with somatic symptoms that are common to many mental disorders. There is evidence that changes in estrogen levels may precipitate certain symptoms. And people who have irregular hormone cycles, which can be influenced by disrupted circadian rhythms, may have seemingly unpredictable symptom onsets. But it would be interesting to correlate them with hormone levels, both gonadal and testosterone. Or I'm sorry, gonadal and thyroid. Additionally, research indicates that are distinct sex hormone actions between the sexes play a critical role in the CNS functioning. So the people who are of different biological genders or, or who have differential levels of hormones, and there wasn't any research that I found on people who are undergoing gender reassignment. So I'm speculating here, may have altered sensory perceptions, may have altered sensations of pain and cardiacs rhythm and things like that. So it would be interesting to explore whether it's the way the body is wired, you know, so those who are biologically assigned female and biologically assigned male will always act differently or whether that changes when hormone levels are rebalanced to the identified gender. So just things, things that I think about. Children as young as five have evidenced limiting somatic complaints, especially stomachache, headache, fatigue and nausea. Now what do we, what do we know about this? The Research has indicated that it's highly comorbid with depression and anxiety in adolescence. Okay, so adolescents who have high levels of anxiety or depression often have stomach aches, headaches, fatigue and nausea. Well, aren't those kind of part and parcel of depression and anxiety? Just a question. And in young children, somatic symptoms were highly correlated with parental accommodation. So the more the parents accommodated the symptoms, the more prevalent the symptoms became. The more the parents focused on the symptoms, the more the child focused on the symptoms. The course of the illness is impacted by age at onset level of impairment, comorbidity, whether comorbidity with physical or mental health issues, harm avoidance. If the person is afraid that they've got a problem, then that harm avoidance, that fear of having to face a problem, may make it more difficult to treat and increase the severity. Rumination and negative affect, which are both associated with the personality characteristic of neuroticism, can also negatively impact the outcome. The more the person ruminates on it and stresses about it, the worse it can get. The more that HPA axis stays activated, the more inflammation, the more systemic dysregulation the person's going to experience. Cooperativeness also, obviously, if they're treatment compliant, then the course is probably going to be different than if they're treatment non compliant. Health literacy also impacts the development if people are able to understand the multiplicity of causes of different symptoms and not just focus on the one catastrophic thing that can actually help. So if they had a loved one, for example, who died of a heart attack or of cancer, yes, that could be something that could happen, but what else could cause that symptom in you? A healthy individual, a person who's health literate, able to evaluate the options more effectively than somebody who just says, oh, this symptom means this diagnosis. Access to medical services also contributes to the development and course. If the person does not have access to adequate, helpful medical services, then they may have symptoms that are perpetual and they don't know what's causing them or how to fix it. And prior health care experiences. If they've been poor, then the person is more likely going to be distrustful of future providers. Somatic symptom disorder is under diagnosed in older adults because the worry is often considered understandable. Well, so maybe the worry is understandable. Does it mean we need to be diagnosing everybody who worries about symptoms in a level that we perceive as excessive? Is there an opportunity for quality of life improvement even if their symptoms are perceived as understandable? That's something that we really need to look at do we need to wait until they meet DSM criteria for something before we try to help people improve their quality of life or manage their symptoms? Cultural stigma related to mental health diagnosis partially explains differences in somatic symptom reporting. Some cultures have what they call idioms of distress that are misunderstood by many providers. So they may be downplayed or ignored. And other times there are cultural exploits, explanations that mean the person is not going to be reporting the same symptoms. Burnout, for example, is one of those cultural explanations. Punishment for doing something bad. Some cultures believe that illnesses are a result or a punishment for doing something bad. Other cultures may believe that people's presenting symptoms are a result of imbalance between the hot and the cold or the damp and the dry, the yin and the yang. So it's important to recognize how people explain things and understand what they're trying to communicate. Somatic symptom disorder has a higher level of suicidal ideation and attempts to due to comorbidity with mood disorders. Well, I don't know about you, but if I've had this ongoing symptom that is disruptive to my life, to my sleep, to my ability to do things, and the medical providers keep telling me there's nothing they can do, there's no underlying cause for it, it's all in my head, or I'm exaggerating how bad it is, then yeah, I'm going to start to feel hopeless and helpless. And the impact of that symptom may be such, and the worry about that symptom may be such that it starts disrupting sleep, which contributes to fatigue and difficulty concentrating. And you can see how very easily someone could also develop comorbid depression. And perception of the cause of the symptoms is also linked to increased suicidal ideation. If people think that, oh my gosh, this symptom means that I've got this terminal illness or I've got this illness that I refuse to live with, then they may be more likely to take matters into their own hands. So we do need to understand people's perception of what's going on and how it's going to impact their quality of life and their sense of, of personal control. Now, illness anxiety disorder. We're moving on from somatic symptom disorder. There are a couple others in this chapter that have very minimal information on them. Illness Anxiety disorder is diagnosed when the individual performs excessive health related behaviors like frequent checking of, you know, moles or heart rate or blood pressure or whatever, extreme lifestyle alterations or intensive ongoing research about a particular symptom or disorder or exhibit maladaptive avoidance of medical care. So they may be either all in and trying to figure out what it is, or they may be all out going, yeah, this might be really bad. So I don't want to know. And I refuse to go seek medical. A medical opinion. Illness anxiety is present for at least six months, but the specific illness may change and it's not better explained by another mental disorder. According to the DSM 5tr preoccupation with having or acquiring a serious illness is a mainstay of illness. Anxiety disorder. And the somatic symptoms are not present or. And this is where it starts to get dicey. If present, they are only mild in intensity. If a medical condition is present or there's a high risk for developing a medical condition like a strong family history, the preoccupation is clearly excessive or disproportionate. Thinking about somebody who's had a family member that died of cancer or heart disease, and they have a strong family history, you know, it's not just one person. It's like the whole family. Is their preoccupation or concern about the issue excessive or disproportionate? Who's to make that decision? And that's really where we need to work with the patient. If the patient considers it disproportionate, okay, you know, let's work with that. However, I think we get into very gray area ethically when we start telling people how valid it is, the intensity of their worry. There's a high level of anxiety and hypervigilance about their health. So all of these things have to be there. They have to do the frequent checking. They have to have a preoccupation with having or acquiring an illness. They have to have it for at least six months, and it's not explained by another medical condition. And there has to be a high level of anxiety and hypervigilance about health. Now, not in the dsm. So this isn't part of the diagnostic criteria, but it's also interesting to consider health anxiety by proxy. And this is when a parent, caregiver, loved one becomes so focused on the symptoms of their child or loved one that they start having all of these other. Meeting all of these other criteria. And, and they want a doctor to diagnose their child. So there is the health anxiety by proxy. This is very different than Munchausen's by proxy, in which there is a clear issue that's going on, a clear physiological problem. But health anxiety by proxy is not in the dsm. However, it is A something that does present more often than not. Illness Anxiety disorder. The prevalence in the DSM 5TR is between 1 and 10%. Not finding a lot of information in PubMed that gives us any other reference for how prevalent it is. The development in course there was virtually no information, although they did mention it was rare in children. The risk factors include a history of abuse, serious illness in self or parent during childhood. If the child remember children think dichotomously, all good, all bad, all healthy, all sick. And if the loved one experienced a serious illness in childhood, then that child probably associated that symptom with catastrophic consequences. So we can see that that schema that was developed may be outdated, but we can see how it develops. And again the history of abuse may be somaticized. They may be having that traumatic memory come out as a physiological reaction as opposed to an overt visual or verbal memory culture related issues to illness anxiety disorder are unknown. The functional consequences the only thing the DSM identifies is that it interferes with relationships and work performance. I would argue that it interferes with a whole lot more than that. If people have a high level of illness and anxiety and they're seeing a lot of doctors, it's going to impact them financially, physically, that anxiety is likely going to impact their ability to get good quality sleep, it's going to impact their energy levels, it's going to impact their immunity. As that HPA axis stays activated, as that anxiety level stays high, cortisol loses its ability as an anti inflammatory and we start seeing pro inflammatory cytokines being secreted a lot more frequently. So we're going to start seeing increased problems in various health functions, if you will. Affectively, people with illness anxiety disorder may have anger, they may have guilt, they may have grief, they may have depression. Cognitively, when you're not getting good sleep, when you're stressed out all the time, when your brain cells are bathed in stress hormones, it is really hard to think clearly, make decisions, problem solve, do all those things that help us function throughout the day and interpersonally. You know, the DSM did note that. So I really emphasize and encourage you to think about the person as a biopsychosocial being and the impact that these conditions either directly or indirectly may have on a person's quality of life. Functional neurological symptom disorder, also known as conversion disorder. One or more symptoms of altered sensory function or voluntary motor function. There are no supporting medical findings. So the person may be muted or may not be able to lift an arm, or may not be able to hear or See, but there's no neurological explanation for it. The MRI comes back clear. It's not better explained by another medical or mental disorder causes clinically significant distress or impairment. It is important for clinicians, mental health clinicians to note that doctors will often perform multiple exams to test the dysfunction and look for what they call internal consistency. So one test for it shows that there is a neurological problem. But another test of the same issue may show that there's not a neurological problem. And the DSM goes through different examples of that. That's not something we're going to get into. However, again, it can feel very invalidating for the individual that's experiencing this neurological symptom. Subtypes need to be noted. It's either with weakness or paralysis, abnormal movement, swallowing issues, speech issues, and that can even be mutism, seizures, numbness or sensory loss. Sensory symptoms or a mixed presentation. It is acute if it lasts less than six months and persistent if it lasts more than six months. And it's important to specify with or without psychological stressors. This one is pretty straightforward. It is often associated with dissociative symptoms such as depersonalization, derealization and dissociative amnesia. However, the prevalence is thought to be less than 1%. Risk factors for functional neurological symptom disorder Emotional dysregulation. Well, we see emotional dysregulation a lot in people with a history of trauma. Therefore, is it emotional dysregulation or the trauma history? A history of abuse or neglect? Well, there's trauma right there or a presence of a neurological disease that causes similar symptoms. So they may have, for example, epilepsy and they may also have non epileptic seizures. Instances resembling functional neurological and dissociative symptoms are common in certain culturally sanctioned rituals and would therefore not qualify for fnsd. Speaking in tongues is one of those examples where somebody's speaking speech becomes dysregulated. A lot of times they also may faint, but that is only within the context of the religious ritual. It is more common in women. And people with functional neurological symptom disorder have a higher rate of suicidality than those with a recognized neurological disease. Maybe due to the perception of hopelessness and helplessness of the doctors. Can't seem to tell you what's wrong. I don't know. Just hypothesizing. Functional consequences according to the DSM are simply physical disability. However, again, and we don't have time to really go through it again in this presentation, but think about the physical, affective, cognitive and relational impact that having a Functional neurological symptom disorder may have on people. Remember, the FNSD does not have an underlying neurological basis to it. So how does that impact, how do people perceive that? How does that impact people's perception of themselves and psychological factors affecting medical conditions. A medical condition is present psychological factors or behaviors that are well established as health risks which adversely impact the medical condition by causing exacerbation, delayed recovery, treatment, non compliance or failure to seek treatment. So for example, people with high levels of anxiety, it may exacerbate their asthma. Other times people may ignore a heart attack because you know they're avoiding the health system and that could cause them to die. If not, go to the emergency room. People who have been diagnosed with diabetes may have a resistance to that diagnosis, either anger about it or what have you and they may engage in behaviors that are contrary, like eating a lot of sugar. Additionally, anxiety and high levels of stress are associated with difficulty managing A1C levels. So there's a lot of things that could go here. It's not better explained by another medical or mental health disorder. For example, people who qualify for alcohol use disorder may drink even though they have hepatitis and that is actually covered in the diagnostic criteria for addiction. Continued engagement in behaviors that are known to cause, known to be exasperated, known to exacerbate medical conditions. Prevalence of is unknown. The development of course, is unclear. Psychological factors affecting other medical conditions must be differentiated from culturally specific coping behaviors such as accessing faith, spiritual or traditional healers or other variations in illness management that are acceptable within the cultural context. So what they're saying is if people don't choose to go through traditional western medicine, that doesn't mean that they are having a psychological issue that's complicating their medical condition. They are following a culturally sanctioned treatment path. Differential diagnosis. Factors that distinguish somatic symptom and related disorders from medical conditions alone include the ineffectiveness of medications, a history of mental disorders, thought that was interesting, unclear triggers or mitigators. So there's no. It's difficult to identify what causes symptoms and or what makes them better. Persistence over a period of several months or more and excessive anxiety. Psychological factors affecting other medical conditions that diagnosis. It's important to recognize that in this disorder the psychological presentation is not considered excessive necessarily. However, it negatively impacts treatment or worsens a presenting physical issue. Okay, so fictitious disorder or malingering we didn't go over. But in, in this one, the individual presents as sick with the intent to deceive. They're faking it. Functional neurologic symptom disorder what used to be called conversion disorder we talked about in this one. The presenting symptom is a loss of function, not distress about particular symptoms. So there is no neurological basis, but they have a loss of function. In illness. Anxiety there are few or minimal somatic symptoms and the anxiety is only about the illness as opposed to other anxiety disorders. In adjustment disorder, a person's anxiety is clearly related to identified medical conditions and does not cause clinically significant impairment and lasts for less than six months. Panic Disorder the physical symptoms or health anxiety occur intermittently and surround the panic attack. The episodic and neurological symptoms are not the only symptoms during a panic attack. So you know, you look through the criteria for panic attacks, you'll see there's a host of symptoms, emotional, cognitive and physical that need to be present. If the person has generalized anxiety, the worry is about a variety of issues, not just their health. If the person has depression, the focus is on depressed mood and anhedonia, not the physical symptoms per se, or if it is focused on the physical symptoms. This health related stress only occurs during a depressive episode. They did not smell specify anything about persistent depressive disorder. Delusional disorder Somatic type the intensity of the conviction about the somatic symptoms is far greater than in people with somatic symptom disorder. So it's just an intensity type diagnosis. However, sometimes in delusional disorder, the delusions may be about something that is objectively not real, like an organ is decaying inside them. Body Dysmorphic Disorder the focus of the distress is on a perceived flaw, not getting an illness, but on a perceived flaw that they have. And it usually involves something in the face or upper torso area. In ocd, recurrent thoughts are more intrusive and focused on preventing getting a disease in the future. And there's a presence of compulsive behaviors. Most of the time with somatic symptom disorder there aren't the compulsive behaviors and the focus is on current symptoms not preventing getting a disease. In psychotic disorders, the individual is unable to acknowledge the possibility that the feared disease may not be present or the somatic delusions may be more desire, more bizarre. Somatic symptom disorders are frequently comorbid with mood disorders, ptsd, ocd, sexual dysfunction in men. Interestingly, they were very specific. Our understanding of many physical disorders is still evolving. Although known to exist since 1904, the American College of Rheumatology didn't officially recognize fibromyalgia until 1990. Likewise, POTS was first described in 1940. So I was wrong in my earlier guess. It was first described in 1940. Yet even today, many doctors doubt the existence of the disorder. It is important for us as clinicians to recognize the negative impact of psychological distress on medical disorders as well as the negative impact of medical disorders on psychological health. We need to be very careful not to invalidate patient perceptions of their distress and instead help them identify strategies to improve their quality of life.