Other Psychiatric Disorders

Somatic Symptom and Related Disorders

Somatic symptom disorder, formerly referred to as somatization disorder or Briquet syndrome, is a dramatic and severely disabling illness. It is widely encountered in medical and surgical practices rather than in psychiatric treatment settings. Previous diagnostic criteria focused on the necessity of multiple unexplained symptoms across multiple body sites. Newer diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders— Fifth Edition (DSM-5) focus on the presence of one or more somatic symptoms that are distressing, resulting in significant disruption of an individual's life, and that are associated with excessive feelings or behaviors related to the symptoms, high levels of anxiety about the symptoms, or excessive time devoted to the symptoms. Somatic symptom disorder is related to other similar disorders, including illness anxiety disorder (excessive preoccupation and worry about illness) and functional neurologic symptom disorder (conversion disorder, with one or more symptoms affecting voluntary motor or sensory function). When all forms of unexplained medical symptoms are lumped together, somatic symptom disorder is surprisingly common; one study found them in more than 30% of patients presenting to neurology clinics. However, the shift of focus away from the symptoms and toward the thoughts, feelings, and behaviors engendered by the symptoms provides an alternative means of addressing distress without “solving” the etiology of the symptoms.

Somatic symptom and related disorders are hard to diagnose. By definition, they are disorders of exclusion, and a full medical workup must precede the diagnosis. This is complicated by the common presence of concurrent physical illnesses in these patients. Additionally, somatic symptom disorders must be distinguished from deliberately feigned illness for secondary gain (malingering) and the intentional production of physical symptoms to obtain the role of patient (factitious disorder). This distinction is notoriously tricky.

Somatic symptom and related disorders, although rarely cured, can often be adequately managed. Such individuals need a primary doctor and should have regularly scheduled visits; if they get to see their doctor only when they are symptomatic, they become more symptomatic. These individuals must be protected from medical and surgical overtreatment. More importantly, these patients require close medical care, as significant disease states can arise over time that may easily be overlooked. Despite their preoccupation with illness, these patients often neglect their health.

Patients with somatic symptom and related disorders benefit from psychiatric treatment. They are often concrete in their thinking and alexithymic—deficient in verbalizing their emotional state—and are suitable targets for psychotherapy. The biggest barrier to treatment (apart from failing to diagnose the disorder) is finding a way to tell the patient that he or she has a psychiatric disorder. One way is to tell the patient that he or she has a chronic illness of unknown etiology whose symptoms are exacerbated by stress.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a common, well-characterized, and treatable neuropsychiatric disorder that begins in childhood and manifests in multiple settings throughout an individual's life. It occurs in about 5% of children and about 2.5% of adults. Affected children are at increased risk for failing at school and developing antisocial personality disorders as well as substance abuse disorders. In most individuals, symptoms of motor hyperactivity lessen with advancing age, whereas problems with inattention, organization, and impulsivity persist. In adults, attentional disorders can present as apparent laziness, lack of focus, and procrastination ( Fig. 42.1 ).

The core symptom domains necessary for the diagnosis of ADHD are (1) inattention and/or (2) hyperactivity and impulsivity. Clinical diagnosis of ADHD requires at least five symptoms from each domain over 6 months. ADHD by definition requires the presence of symptoms prior to age 12 years. Adults with ADHD must be distinguished from adults with new complaints of boredom or impaired attention and no past history of childhood ADHD. For the latter patients with new onset of cognitive complaints, a broader differential is generated to include neurodegenerative disease, vitamin deficiencies, affective disorders, endocrine disorders, or normal aging. Adult recollection of childhood symptoms is generally inaccurate; therefore clinical diagnosis should include neuropsychologic testing and review of records. Several screening tools are available for routine clinical use and monitoring.

ADHD must also be distinguished from mania or hypomania. Both groups of patients can be hyperactive with cognitive dysfunction; however, patients with mania or hypomania are also irritable, euphoric, and overtalkative. This distinction can be difficult, in part because of the coexistence of these disorders. Treatment of the affective disorder is generally prioritized.

Imaging studies may demonstrate anatomic abnormalities, such as atrophy or asymmetry in the prefrontal cortex, striatum, or cerebellum. Functional imaging may show decreased frontal and striatal perfusion, especially during tests of sustained attention.

Stimulant medications are the mainstay of treatment. They are highly effective and have few side effects when used correctly. Although there are legitimate concerns that these medications may promote illicit drug use, clinical studies demonstrate that appropriate treatment actually decreases future use of illicit drugs. Atomoxetine and other noradrenergic antidepressants are reasonable alternatives for patients who misuse or cannot tolerate stimulants.

Significant objections are raised to the current approaches for the diagnosis and treatment of ADHD. These stem from the fear that children are being overdiagnosed and then inappropriately medicated. In reality, some children are inappropriately treated, but many others are not diagnosed appropriately with ADHD. The failure to diagnose and treat ADHD in children is as undesirable as misdiagnosis and overtreatment.

Panic Disorder

ED staff members frequently encounter patients with panic disorder. These individuals experience unpredictable and sudden bouts of intense anxiety and frightening physical symptoms, leading them to fear they are having a heart attack, stroke, or other medical emergency. Patients with panic disorder are focused on the minute details of their symptoms and tend to make catastrophic self-diagnoses based on minor aches, palpitations, and shortness of breath ( Fig. 42.2 ). They may present repeatedly to the ED with symptoms such as dyspnea, chest pain, tachycardia, and faintness. Typically these patients are not reassured by a negative examination and may present again a few days later with the same complaints. Between episodes they may feel entirely well, but more commonly they remain anxious and vigilant for signs of the next attack.

Many individuals with panic attacks develop agoraphobia. Agoraphobia is not solely—as the word would suggest—a fear of open spaces but also a fear of being isolated from help and support. Patients with agoraphobia avoid public transportation, open spaces, crowds, or being alone outside the home. Eventually such patients may become so fearful that they cannot leave home without being accompanied. The presence of panic or intense anxiety in patients with mood disorders is a well-established risk factor for suicide. It is unclear whether panic disorder in isolation, without a major depressive disorder, heightens this risk.

Intravenous lactic acid infusion, which mimics respiratory acidosis, reproduces the symptoms of panic attacks in many patients. This has led to postulation of the “suffocation alarm” theory of panic disorder—that affected individuals are overly sensitive to minor changes in blood pH and PCO ₂ . Hence asthma, the exacerbation of chronic obstructive pulmonary disorder, and pulmonary embolus are some of the respiratory disorders that must be excluded in these patients. Other conditions that must be excluded are cardiac arrhythmias, myocardial infarction, ingestion of sympathomimetics (particularly cocaine), excess caffeine, alcohol and sedative-hypnotic withdrawal, hypoglycemia, partial complex seizures, and, rarely, pheochromocytoma or carcinoid tumors.

Psychotherapeutic approaches to panic disorder include patient education about the syndrome's benign natural history and remediation of patients’ catastrophic thinking. For some this is sufficient, although most phobic patients also need a course of graded exposure to feared situations.

Many patients also require pharmacologic management. Benzodiazepines abort panic attacks quickly and can be used as needed if attacks are infrequent. Serotonergic antidepressant medications are the first choice for extended treatment. Anxious patients are sensitive to the initial activating or anxiogenic effects of antidepressants; therefore treatment should begin with lower-than-usual doses. Monoamine oxidase (MAO) inhibitors may work when other antidepressants are ineffective. However, caution is needed with MAO inhibitors because of their potential for serious side effects.