Relevant Psychiatry for the Neurologist
Financial Disclosures Focus on somatic symptom and related disorders, plus catatonia
Descartes Li, M.D. Clinical Professor University of California, San Francisco
[email protected]
none
https://commons.wikimedia.org/wiki/File:E mil_Kraepelin_1926.jpg
Outline • Illness Anxiety Disorder • Conversion Disorder – (Functional Neurological Symptom disorder)
• Factitious Disorder • Catatonia
Outline • Illness Anxiety Disorder • Conversion Disorder – (Functional Neurological Symptom disorder)
• Factitious Disorder • Catatonia
Case Vignette
Case Vignette
41yo man with recurrent worries that he has a brain tumor. Denies any other symptoms. Repeated almost weekly visits to various physicians, numerous brain MRI scans.
https://commons.wikimedia.org/wiki/File:W oody_Allen_(2006).jpeg
https://youtu.be/N4BSJ7YGClE (4min)
DSM-5 Criteria for Illness Anxiety Disorder A. Preoccupation with having or acquiring a serious illness. B. Somatic symptoms are not present or are only mild C. High level of anxiety about health, and easily alarmed about personal health status. D. Excessive health-related behaviors or maladaptive avoidance E. at least 6 months F. Not better explained by another disorder.
Formerly known as
hypochondriasis
Behavior Perspective
Behavior Choice Consequences
What is the difference between somatic symptom disorder and illness anxiety disorder? • Both may present with anxiety • Illness anxiety disorder with no symptoms (or only mild), and fears developing an illness • Somatic symptom disorder often has a medical condition with symptoms, but the reaction to these symptoms is maladaptive
Rumination increased likelihood Consequent beh worsened symptoms
[Somatic Symptom Disorder]
Keep in mind
A. Somatic Symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life. B. One or more of: Excessive thoughts, feelings, and/or behaviors related to these somatic symptoms or associated health concerns: 1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms (thoughts) 2) Persistently high level of anxiety about health or symptoms (feelings) 3) Excessive time and energy devoted to these symptoms or health concern (behaviors) C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is persistent and lasts > 6 months.
• Get a careful history, including pt’s perspective. • Prior responses, and consequences. • Consider the diagnosis in individuals with multiple complaints, such as pain, fatigue, or gastrointestinal problems. • Individuals often have both a diagnosed medical condition and abnormal behaviors and thoughts related to this condition. • These individuals are genuinely suffering.
Questions?
[Examples of Disease Entities That Overlap with Somatic Symptom and Related Disorders] Specialty Primary care Cardiology Gastroenterology Urology Immunology ENT Neurology
Disease Entity Chronic fatigue syndrome Fibromyalgia Atypical chest pain Irritable bowel syndrome Interstitial cystitis Multiple chemical sensitivities Temporomandibular joint syndrome Psychogenic non-epileptic seizures (Conversion disorder)
Can be conceptualized as “contested illnesses” See Dumit 2006. Illnesses you have to fight to get: Facts as forces in uncertain, emergent illnesses. Social Science & Medicine 62 (2006) 577–590
1. Psychosis – Work with psychiatrist to manage delusions – If psychosis with poor insight, recommend: I Am Not Sick, I Don't Need Help: How To Help Someone With Mental Illness Accept Treatment, by Xavier Amador
– Consider diagnoses besides schizophrenia
Key rule outs for somatic symptom disorder and related disorders 1. 2. 3. 4.
Psychosis Anxiety disorders, especially OCD Cultural syndromes Factitious disorders*
Each has a different management approach. *separate section on factitious disorders
2. Obsessive Compulsive Disorder – If OCD is diagnosed, treat using SSRIs/clomipramine and Exposureresponse prevention
For OCD with disease obsession, what would the exposure and response prevention look like?
Exposure-Response Prevention
Increased anxiety response prevention
exposure
obsessions
desensitization
compulsions
3. Cultural syndromes – May overlap with “contested illnesses” (eg, Morgellon’s) – Need to understand specifics of each syndrome
Decreased anxiety
Management of Chronic Major Somatization* 1) Care Rather Than Cure Don’t try to eliminate symptoms completely Focus on coping and functioning as goals of treatment 2) Diagnostic and Therapeutic Conservatism Review old records before ordering tests Respond to requests carefully (remember these pts often have medical conditions)
Benign remedies (Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9)
Management of Chronic Major Somatization* 3) Validation of Distress Don’t refute or negate symptoms Patient-physician relationship not predicated on symptoms Focus on social history Regular visits (not prn)
– consider scheduled telephone contacts
(Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9)
Management of Chronic Major Somatization* 4) Providing a Diagnosis Emphasize dysfunction rather than pathology Describe amplification process provide specific example, if appropriate Cautious reassurance, dispel: “Every symptom must have an explanation” Introduce stress model of disease, if appropriate 5) Mental Health Consultation To diagnose psychiatric comorbidity For recommendations about pharmacotherapy For cognitive-behavioral therapy to improve coping or psychotherapy
Outline • Illness Anxiety Disorder • Conversion Disorder – (Functional Neurological Symptom disorder)
• Factitious Disorder • Catatonia
(Adapted from Barsky AJ. Clinical Crossroads: A 37-Year-Old Man With Multiple Somatic Complaints. JAMA 1997; 278: 673-9)
Case Vignette
16yo girl with new onset tics
What Happened to the Girls in Le Roy?
https://youtu.be/cCED0PQqXZg http://www.nytimes.com/2012/03/11/magazine/teenage-girlstwitching-le-roy.html
What Happened to the Girls in Le Roy?
DSM-5 Criteria for Conversion Disorder (Functional Neurological Symptom Disorder)
A. One or more symptoms of altered voluntary motor or sensory function. B. Incompatibility between the symptom and recognized neurological or medical conditions. C. Is not better explained by another medical or mental disorder. D. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Specify symptom type: abnormal movement, seizures, speech, sensory loss, etc. Specify if: acute or persistent Specify if: with or without psychological stressor (specify stressor)
http://www.nytimes.com/2012/03/11/m agazine/teenage-girls-twitching-leroy.html
History of conversion disorder
Hystero-epilepsy
DSM-II: Hysterical neurosis Hysteria psychosomatic somatoform
the DSM-II, hysterical neurosis
History of the DSM DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994) DSM-5 (2013)
Jean-Martin Charcot 1825-1893
Other examples of conversion disorder • psychogenic non-epileptic seizures (PNES) aka pseudoseizures • Sudden paralysis of right upper extremity • Sudden onset of unilateral hearing loss • Also hysterical blindness, incontinence
Risk factors
Characteristics of PNES 1. triggered by stress 2. no incontinence 3. no post-ictal confusion 4. speaking during the episode 5. >10minutes 6. always witnessed 7. resolution with psychosocial interventions
How do you treat Conversion disorder?
http://www.neurosymptoms.org/
Conversion disorder management
https://vimeo.com/ 136982979
The Fringe 2015: Hidden World of Functional Disorders
conversion disorder management • Can be very useful to be straightforward and educational • Attitude and word choice may be key • Reassure that condition usually resolves with treatment (PT, stress reduction) • However, conversion may overlap with management of factitious disorder
Outline • Illness Anxiety Disorder • Conversion Disorder – (Functional Neurological Symptom disorder)
• Factitious Disorder • Catatonia
Case Vignette 24-year-old veterinary student with a history of knee osteosarcoma and chemotherapy passed out while on rounds one morning. Labs revealed: Hemoglobin of 5.2g/dL, MCV112. She was admitted to the hospital. The next day, her parents flew in from out of town and found numerous bottles of the patient’s blood in her apartment.
What happened? What is the most likely psychiatric diagnosis?
Factitious disorder* assessment tips
• Trace development of symptoms over time – Symptoms often emerge or change over time (shaping)
• Look for modeling, rewards, explicit instructions, medical backgrounds • Patients are often immature or dependent, with limited problem solving skills. • He or she may be easily suggestible and hypnotizable http://hypnosis.tools/suggestibility-scales.html *These tips also apply to conversion disorder
Factitious Disorder Imposed on Self
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. B. Presents self to others as ill, impaired, or injured. C. Evident even in the absence of obvious external rewards. D. Not better explained by another mental disorder Specify: Single episode or Recurrent episodes
Munchausen’s syndrome non-DSM term for a severe form of factitious disorder - Characterized by recurrent hospitalization, travelling, and dramatic, untrue, and extremely improbable tales of their past experiences
Is this factitious disorder? (what causes factitious disorder?)
Factitious disorder management Remember: • The patient’s need to be consistent can be the crucial sustaining factor • Confrontation is often dramatically unsuccessful What about the 16 other girls? Malingering? Cultural syndrome? Mass hysteria?
• Successful outcome often depends upon persuasion and countersuggestion
Factitious disorder management • Sometimes ignoring the symptoms is sufficient • Communicate expectation of resolution • Suggest a disease course • Offer improvement without embarrassment
Take Home Points • Medical conditions and somatic symptom and related disorders often co-occur (eg, epilepsy and seizures of non-epileptic origin)
• Graduated prescriptions: e.g., physical therapy • Let go of the need to be right • For more complex cases, a team/systems approach is critical (high level expertise required)
The Resignation Syndrome
https://www.newyorker.com/magazine/201 7/04/03/the-trauma-of-facing-deportation
• It may be impossible to prove the diagnosis definitively. • Countertransference may be intense, and may be a clue to the diagnosis • A consultation from outside the team can be essential.
Resignation Syndrome: Catatonia? Culture-Bound? Not Catatonia!
Sallin K et al Front. Behav. Neurosci., 29 January 2016 | https://doi.org/10.3389/fnbeh.2016.00007 https://www.frontiersin.org/articles/10.3389/fnbeh.2016.00007/full
uppgivenhetssyndrom
Catatonia
Outline • Illness Anxiety Disorder • Conversion Disorder – (Functional Neurological Symptom disorder)
• Factitious Disorder • Catatonia
• “insanity of tension” • identified in 1874 by Karl Kahlbaum • 26 cases – 12 with severe depression – 3 with neurosyphilis – 2 with TB
https://commons.wikimedia.org/wiki/File:Karl _Ludwig_Kahlbaum.JPG
16 behaviors: negativism, staring, grimacing, stereotypy, mannerisms, echophenomena, waxy flexibility Weder ND et al. Catatonia: A Review. Annals of Clinical Psychiatry,20:2,97 — 107. DOI: 10.1080/10401230802017092
Catatonia • Kraepelin assigned catatonia to the category of dementia praecox • Bleuler (1907) designated catatonia as a marker of schizophrenia • 1950s, treatment with antipsychotics frequently led to fever, hypertension, tachycardia, muscular rigidity neuroleptic malignant syndrome
Diagnoses associated with catatonia study
n
Bpdo Mood d/o
55
Schizoph renia 7%
Abrams + Taylor Huang et al Benegal et al Lee et al
34 65 24
26% 26% 54%
23% 23% 17%
9%
Also, endocrine abnormalities, infections, electrolyte imbalances, epilepsy, strokes (of anterior brain region), withdrawal from benzodiazepines
Risk factors • • • • •
h/o perinatal infections Prior episodes of catatonia h/o eps from medications Epilepsy Exposure to meds that lower seizure threshold • Long term exposure to anticholinergic drugs • Frontal or basal ganglia diseases
[DSM5 definition of catatonia ICD F06.1] A. The clinical picture is dominated by three (or more) of the following symptoms: 1. Catalepsy (i.e., passive induction of a posture held against gravity) 2. Waxy flexibility (i.e., slight and even resistance to positioning by examiner) 3. Stupor (no psychomotor activity; not actively relating to environment) 4. Agitation, not influenced by external stimuli 5. Mutism (i.e., no, or very little, verbal response [Note: not applicable if there is an established aphasia])
[DSM5 organization of catatonia] • Catatonia associated with another mental disorder (catatonia specifier), ICD-10 F06.1
• Catatonic disorder due to another medical condition, ICD-10 F06.1 • Unspecified catatonia No longer only a subtype of schizophrenia
[DSM5 definition of catatonia] Criterion A continued. Underlined symptoms more common 6. Negativism (i.e., opposing or not responding to instructions or external stimuli) 7. Posturing (i.e., spontaneous and active maintenance of a posture against gravity) 8. Mannerisms (i.e., odd caricature of normal actions) 9. Stereotypies (i.e., repetitive, abnormally frequent, nongoal directed movements) 10. Grimacing 11. Echolalia (i.e., mimicking another's speech) 12. Echopraxia (i.e., mimicking another's movements) Periods of hypokinesis and hyperkinesis may alternate in a predictable fashion
Video of catatonia
https://www.youtube.com/watch?v=_s1lzxHRO4U (4min)
Differential diagnoses 1. Malignant catatonia 2. Malignant hyperthermia 3. Neuroleptic malignant syndrome 4. Serotonin syndrome 5. Extrapyramidal symptoms 6. Locked in Syndrome 7. Elective mutism 8. Delirious mania 9. Delirium 10. Akinetic mutism N.B. Bolded conditions may be considered conditions related to catatonia in pathophysiology
[Pathophysiology?] • Frontal cortex striatum pallidum thalamus cortex • But Striatum inhibits the pallidum, which in turn inhibits the thalamus • If striatum is damaged or inhibited, the pallidum will inhibit thalamus in unopposed fashion • Ambien inhibits pallidum
Striatum inhibited in catatonia?
Basal Ganglia https://en.wikipedia.org/wiki/Basal_ganglia
Benzo’s inhibit pallidum By Created by Andrew Gillies [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/)], via Wikimedia Commons
Red lines are inhibitory Green lines are excitatory
Benzo’s in catatonia • Acute remission rates around 80% • Typically respond within minutes to iv benzodiazepines and 1-2 hours with oral formulations. • However, tolerance to benzodiazepines does occur • Chronic catatonia (>3 weeks) associated with schizophrenia responds less well
By The original uploader was RobinH at English Wikibooks - Transferred from en.wikibooks to Commons., CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=36970335
ECT in catatonia • Not many well-designed studies, available evidence generally points to a favorable response • May directly treat underlying illness (mania or depression) • Lorazepam may be more effective after ECT is initiated
[Treatment algorithm]
[Treatment algorithm] A trial of lorazepam as an initial step is warranted as it is a safe therapeutic option with a success rate of about 80%. 1. Start with lorazepam iv 1–2 mg challenge with a rating of catatonic signs after the first hour. 2. Then up to 24 mg a day with 6 full days of treatment followed by the taper to the optimum dose. 3. If the patient failed to respond adequately to lorazepam, then bilateral ECT treatments is warranted. (consider earlier use of ECT for autonomic instability, hyperthermia or malignant catatonia). 4. If patient responds to ECT within the first few treatments, at least 6 sessions should be administered.
5. If the patient fails to respond to trials of lorazepam and/or ECT, a trial of memantine, carbamazepine, or topiramate as monotherapy or in combination with lorazepam or ECT should be attempted 6. If the patient responds to medications or ECT, they should be continued on those medications for 9–12 months or on ECT for 6 months.
Weder ND et al. Catatonia: A Review. Annals of Clinical Psychiatry,20:2,97 — 107. DOI: 10.1080/10401230802017092
Next topics?
Summary • Illness Anxiety Disorder • Conversion Disorder – (Functional Neurological Symptom disorder)
• Factitious Disorder • Catatonia
• • • • •
Tardive dyskinesia Anxiety disorders Agitation in dementia* Neuropsychiatric syndromes* More on the electroconvulsive therapy