Psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures are episodes of movement, sensation, or behaviors that are similar to epileptic seizures but do not have a neurologic origin; rather, they are somatic manifestations of psychologic distress. Patients with psychogenic nonepileptic seizures frequently are misdiagnosed and treated for epilepsy. Video-electroencephalography monitoring is preferred for diagnosis. From 5 to 10 percent of outpatient epilepsy patients and 20 to 40 percent of inpatient epilepsy patients have psychogenic nonepileptic seizures. These patients inevitably have comorbid psychiatric illnesses, most commonly depression, posttraumatic stress disorder, other dissociative and somatoform disorders, and personality pathology, especially borderline personality type. Many patients have a history of sexual or physical abuse. Between 75 and 85 percent of patients with psychogenic nonepileptic seizures are women. Psychogenic nonepileptic seizures typically begin in young adulthood. Treatment involves discontinuation of antiepileptic drugs in patients without concurrent epilepsy and referral for appropriate psychiatric care. More studies are needed to determine the best treatment modalities.     

Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders

Half of all outpatient encounters are precipitated by physical complaints, of which one third to one half are medically unexplained symptoms, and 20% to 25% are chronic or recurrent. Many of the patients suffer from one or more discrete symptoms, whereas others have functional somatic syndromes. Individual symptoms and somatic syndromes are associated with impaired quality of life, increased health care use, and diminished patient and provider satisfaction. This article provides an overview of (1) unexplained symptoms and somatization; (2) limitations of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition in classifying somatoform disorders; (3) predictors of psychiatric comorbidity in patients who have physical symptoms; and (4) measurement and management of symptoms.     

Diagnostic schema for somatic and psychologic complaints

The patient with somatic complaints may have a "clear-cut" medical condition or a somatoform disorder. The patient with psychologic complaints may have a "clear-cut" psychiatric disturbance or an organic brain disorder. Medical conditions may be worsened or complicated by psychologic factors. The challenge to the physician is to discover which category best encompasses the patient's symptoms so that a rational plan of management can be devised.     

Somatisation disorder in a British teaching hospital.

We describe 33 patients (31 women, 2 men; mean age 47 years) who satisfied research criteria for somatization disorder (SD), a disorder characterised by persistent or recurrent unexplained somatic symptoms beginning before the age of 30. The mean duration of symptoms was 30 years (range 12-57). Twenty patients had co-existing physical disease: seven (21%) had histories of chronic physical disease in childhood, whereas in 13 (39%) the physical disorders began in adult life, after many years of somatic complaints, and were largely coincidental. All had been repeatedly investigated for their symptoms. Twenty-one patients (64%) were receiving medication for spurious physical disorders, most commonly 'angina' and 'asthma'. Hysterectomies had been performed in 16 (52%) of the 31 women at a mean age of 37 years, but pathology was detected in only two. Twenty-nine patients (88%) had received previous treatment for psychiatric illness, and 20 (61%) were receiving invalidity benefits. British psychiatrists do not usually diagnose SD, but focus selectively on symptoms that suggest more familiar psychiatric syndromes. Similarly, medical specialists often diagnose 'functional syndromes' affecting the system that interests them. Over time these patients acquire spurious organic diagnoses and develop physical disorders that make the assessment of new symptoms more difficult. Disability is invariably in excess of what might be predicted from physical findings. We conclude that a diagnosis of SD draws attention to a group of patients who are chronically ill and unresponsive to conventional medical and psychiatric treatment. They use a lot of resources to little avail and thus merit more research.     

Terrorism and weapons of mass destruction: managing the behavioral reaction in primary care

Any terrorist attack using weapons of mass destruction will result in substantial psychological trauma and stress. Primary care and emergency clinics will likely see patients who have stress-related emotional or physical symptoms, or exacerbations of preexisting health concerns. Significant psychological and behavioral reactions to an attack with weapons of mass destruction are certain, include both group and individual reactions, and will follow a predictable course. Possible group reactions include mass panic, acute outbreaks of medically unexplained symptoms, and chronic cases of medically unexplained physical symptoms. Possible individual reactions include psychiatric disorders such as posttraumatic stress disorder, which occurs in approximately 30% of people exposed to extreme trauma. Most people have symptoms of arousal that are normal reactions to abnormal events and that resolve with rest, reassurance, support, and education. Mandatory debriefings are not recommended, and medications may be used when more conservative measures are not sufficient.     

The role of venlafaxine and duloxetine in the treatment of depression with decremental changes in somatic symptoms of pain, chronic pain, and the pharmacokinetics and clinical considerations of duloxetine pharmacotherapy

Chronic pain is among the most common conditions to initiate medical care; 40% of patients victimized by chronic pain are not under the supervision of a physician, and about 70% of patients with severe pain are receiving pain medical care. About dollar 100 billion is an annual estimated cost representing loss of productivity, increased medical costs, and income loss. Major depressive disorder is not infrequently encountered in daily clinical practice often presenting with somatic complaints that include varieties of pain, and these may be so prominent as to direct the treatment to the somatic complaint evaluation to the exclusion of underlying psychopathology. Anxiety disorders and other psychiatric disorders may also present with such a somatization evaluation focus. Serotonin noradrenergic reuptake inhibitors (SNRIs), ie, venlafaxine and duloxetine, offer benefits over tricyclic antidepressants and serotonin reuptake inhibitors. Years of experience with venlafaxine representing a first-line pharmacotherapy for depression and anxiety have benefited patients presenting with somatic symptoms with a robust onset. A more rapid achievement by venlafaxine of remission and a high-quality pharmacokinetic and pharmacodynamic profile lead to patient compliance and facilitate both fewer relapses and recurrences. Duloxetine is broadly discussed, revealing pharmacokinetic, pharmacodynamic, adverse/side effects, cautions with requisite patient-specific selection, and laboratory monitoring. The management of somatic pain complaints of physical and psychiatric origin is discussed.     

SOMATISATION DISORDER IN A BRITISH TEACHING HOSPITAL

SUMMARY We describe 33 patients (31 women, 2 men; mean age 47 years) who satisfied research criteria for somatization disorder (SD), a disorder characterised by persistent or recurrent unexplained somatic symptoms beginning before the age of 30. The mean duration of symptoms was 30 years (range 12–57). Twenty patients had co-existing physical disease: seven (21%) had histories of chronic physical disease in childhood, whereas in 13 (39%) the physical disorders began in adult life, after many years of somatic complaints, and were largely coincidental. All had been repeatedly investigated for their symptoms. Twenty-one patients (64%) were receiving medication for spurious physical disorders, most commonly ‘angina’ and ‘asthma‘. Hysterectomies had been performed in 16 (52%) of the 31 women at a mean age of 37 years, but pathology was detected in only two. Twenty-nine patients (88%) had received previous treatment for psychiatric illness, and 20 (61%) were receiving invalidity benefits. British psychiatrists do not usually diagnose SD, but focus selectively on symptoms that suggest more familiar psychiatric syndromes. Similarly, medical specialists often diagnose 'functional syndromes' affecting the system that interests them. Over time these patients acquire spurious organic diagnoses and develop physical disorders that make the assessment of new symptoms more difficult. Disability is invariably in excess of what might be predicted from physical findings. We conclude that a diagnosis of SD draws attention to a group of patients who are chronically ill and unresponsive to conventional medical and psychiatric treatment. They use a lot of resources to little avail and thus merit more research.     

The recognition, diagnosis, and treatment of mental disorders by primary care physicians

A valid and reliable vignette-based measure of DSM-III psychiatric diagnostic knowledge was administered to practicing primary care physicians (PCPs; generally, internal and family practice medicine) and mental health professionals (MHPs, in psychiatry and psychology). Recognition, diagnosis, and treatment recommendations were measured for 14 different disorders. Contrary to other reports, PCPs consistently recognized the presence of mental disorder and did so virtually as well as MHPs, although both PCPs and MHPs showed more under-recognition than over-recognition. Diagnostic accuracy, however, was substantially lower, with that of MHPs exceeding PCPs for the general classes of affective, anxiety, somatic, and personality disorders, but not for the organic disorders. In making specific diagnoses, significantly fewer PCPs than MHPs gave an accurate diagnosis for eight of the 14 disorders: dysthymic disorder, major depression with psychotic features, agoraphobia with panic attacks (marginally), generalized anxiety disorder, adjustment disorder with anxious mood (marginally), psychologic factors affecting physical condition, and two personality disorders. Overall, PCPs were most accurate in identifying organic disorders (81% correct), least accurate in identifying the personality disorders (14%), and intermediate in identifying the affective (47%), anxiety (49%), and somatic disorders (49%). In most cases, both PCPs and MHPs preferred referral to treatment in primary care, but more PCPs than MHPs recommended treatment in primary care for certain anxiety and somatic disorders. Some differences in the recommended use of antidepressants in primary care were also found. Implications for the provision of mental health care by primary care physicians are discussed.     

Physical symptoms that predict psychiatric disorders in rural primary care adults

Rationale, aims and objectives There is a robust association between physical symptoms and mental distress, but recognition rates of psychiatric disorders by primary care doctors are low. We investigated patient‐reported physical symptoms as predictors of concurrent psychiatric disorders in rural primary care adult outpatients. Method A convenience sample of 1092 patients were assessed with a two‐stage diagnostic system consisting of a brief screening questionnaire and a clinician‐administered semi‐structured interview that linked common physical symptoms with the concurrent presence of psychiatric disorders. Results Somatoform physical symptoms were highly predictive of the concurrent presence of a psychiatric disorder, with odds ratios ranging from 10.4 (fainting spells) to 54.6 (shortness of breath). Aggregate analysis of somatoform and non‐somatoform symptoms relative to no physical symptom produced odds ratios of 3.0 or higher for headaches, chest pain, dizziness, sleep problem, shortness of breath, tired or low energy, and fainting spells. As the number of symptoms (especially somatoform) increased, the odds of a psychiatric disorder increased. Conclusion Although individual physical symptoms are valid triggers for suspecting a psychiatric disorder, the most powerful correlates are total number of physical complaints and somatoform symptom status.     

Acute and post-traumatic stress disorder after spontaneous abortion

When a spontaneous abortion is followed by complicated bereavement, the primary care physician may not consider the diagnosis of acute stress disorder or post-traumatic stress disorder. The major difference between these two conditions is that, in acute stress disorder, symptoms such as dissociation, reliving the trauma, avoiding stimuli associated with the trauma and increased arousal are present for at least two days but not longer than four weeks. When the symptoms persist beyond four weeks, the patient may have post-traumatic stress disorder. The symptoms of distress response after spontaneous abortion include psychologic, physical, cognitive and behavioral effects; however, patients with distress response after spontaneous abortion often do not meet the criteria for acute or post-traumatic stress disorder. After spontaneous abortion, as many as 10 percent of women may have acute stress disorder and up to 1 percent may have post-traumatic stress disorder. Critical incident stress debriefing, which may be administered by trained family physicians or mental health practitioners, may help patients who are having a stress disorder after a spontaneous abortion.     

Attention-deficit/hyperactivity disorder

ADHD continues to be one of the most common psychiatric disorders in children and is recognized increasingly as a common psychiatric disorder in adults. Diagnosis of the disorder requires careful consideration of other psychiatric and medical disorders that may mimic symptoms of ADHD. Comorbid disorders are common in patients with ADHD and require careful attention. A recommended diagnostic evaluation for children and adults includes the completion of a psychiatric interview, rating scales from multiple informants, and often individually tailored psychologic testing. Pharmacologic treatment options include the first-line stimulant agents for adults and children and TCAs and atypical antidepressants as second-line agents. Behavioral interventions may help reduce ADHD symptoms and address comorbid conditions in children. Future research is needed to identify the optimal psychosocial treatment for adults with ADHD.     

Are pain disorder and somatization disorder valid diagnostic entities?

Physicians and other clinicians who treat patients with chronic pain have doubtless recognized the interplay of various psychological and somatic variables in their patients’ pain. Notwithstanding, there continues to be primary emphasis on the somatic factors, and continued neglect of the psychological. This article asserts that pain disorder and somatization disorder are indeed valid diagnostic entities, and that their respective incidence and prevalence are quite high both in patients with chronic pain and in the primary care setting. These diagnoses are compared and contrasted, along with the related diagnosis of the psychological factors affecting physical condition. Guidelines for assessment of these conditions are provided, as are recommendations as to when to refer patients for further psychological and psychiatric assessment and treatment.     

Insomnia

Insomnia is a common problem that is chronic for many individuals. Multiple processes, including psychologic, physiologic, and environmental factors, can influence insomnia, and their effects can shift over time. Accordingly, the evaluation of patients who have insomnia should be broad in scope. Insomnia represents a clinical problem with significant daytime consequences, associations, and comorbidities. Several nosologies categorize insomnia into specific diagnoses. Useful minimal criteria for an insomnia disorder include persistent nighttime symptoms with daytime distress or impairment. Specific treatments, addressing particular underlying causes,and general pharmacologic and nonpharmacologic strategies may play valuable roles in the management of insomnia patients. The effective treatment of insomnia can have further benefits in decreasing the likelihood of future psychiatric symptoms.     

Somatoform disorders

The somatoform disorders are a group of psychiatric disorders that cause unexplained physical symptoms. They include somatization disorder (involving multisystem physical symptoms), undifferentiated somatoform disorder (fewer symptoms than somatization disorder), conversion disorder (voluntary motor or sensory function symptoms), pain disorder (pain with strong psychological involvement), hypochondriasis (fear of having a life-threatening illness or condition), body dysmorphic disorder (preoccupation with a real or imagined physical defect), and somatoform disorder not otherwise specified (used when criteria are not dearly met for one of the other somatoform disorders). These disorders should be considered early in the evaluation of patients with unexplained symptoms to prevent unnecessary interventions and testing. Treatment success can be enhanced by discussing the possibility of a somatoform disorder with the patient early in the evaluation process, limiting unnecessary diagnostic and medical treatments, focusing on the management of the disorder rather than its cure, using appropriate medications and psychotherapy for comorbidities, maintaining a psychoeducational and collaborative relationship with patients, and referring patients to mental health professionals when appropriate.     

Das Fibromyalgiesyndrom — eine somatoforme (Schmerz)störung?

The hypothesis that fibromyalgia (FM) should be classified as a somatoform disorder was assessed by reviewing current clinical studies. According to the ICD-10, somatic illness beliefs of the patient, high health care utilization, and frustrating patient-doctor relationships are diagnostic criteria of somatoform disorders. For the diagnosis of a somatoform pain disorder, a temporal association between the manifestation of pain and emotional or psychosocial conflicts and the exclusion of a depressive disorder are additionally required. Empirical studies demonstrate a higher lifetime and current prevalence of psychiatric disorders, childhood adversities, life events, and daily hassles and a higher health care utilization of FM patients. Studies also reveal that most patients believe that both somatic and psychosocial factors have caused their disorder. The patient-doctor relationship is characterized to be disappointing for both. Yet in all studies there were patients who did not fulfill the ICD-10 criteria of a somatoform (pain) disorder. A biopsychosocial model of FM differentiating between biological as well as psychosocial predisposing, triggering, and perpetuating factors in the pathogenesis of FM is presented as an alternative model. Hopefully the biopsychosocial model and the distinction of subgroups will enable more differentiated and tailored psychotherapeutic and pharmacological treatment strategies.     

In pursuit of perfection: a primary care physician's guide to body dysmorphic disorder.

Body dysmorphic disorder is an under-recognized chronic problem that is defined as an excessive preoccupation with an imagined or a minor defect of a localized facial feature or body part, resulting in decreased social, academic and occupational functioning. Patients who have body dysmorphic disorder are preoccupied with an ideal body image and view themselves as ugly or misshapen. Comorbid psychiatric disorders may also be present in these patients. Body dysmorphic disorder is distinguished from eating disorders such as anorexia nervosa that encompass a preoccupation with overall body shape and weight. Psychosocial and neurochemical factors, specifically serotonin dysfunction, are postulated etiologies. Treatment approaches include cognitive-behavioral psychotherapy and psychotropic medication. To relieve the symptoms of body dysmorphic disorder, selective serotonin reuptake inhibitors, in higher dosages than those typically recommended for other psychiatric disorders, may be necessary. A trusting relationship between the patient and the family physician may encourage compliance with medical treatment and bridge the transition to psychiatric intervention.     

Psychiatric symptoms in cancer patients. Is the cause organic or psychologic?

Because cancer and its treatment have so many effects on the CNS, the diagnosis of psychiatric symptoms in cancer patients is problematic. Naturally there are psychologic and psychosocial issues that often sufficiently explain why a patient appears distressed. Dealing with psychologic adjustment is always an important part of the management of patients with severe medical, as opposed to psychiatric, illness, whether or not biologic components of the psychologic problem can be identified and addressed. The most frequent error physicians make in evaluating psychiatric symptoms is to assume that a psychologic explanation is sufficient. Expressions such as "Wouldn't you be depressed if you had cancer?" are often used to excuse failure to pursue further evaluation. Careful reviews of cases in which cancer patients were labeled as having psychologic problems have consistently shown a high incidence of misdiagnosis. Correct diagnosis and treatment of an underlying organic disorder can alleviate symptoms that impair the patient's innate coping resources, allowing him or her to grapple more effectively with adverse circumstances.     

Identifying patients at risk for,and treatment of major psychiatric complications of cancer

A critically important aspect of supportive care in cancer is the prompt recognition and effective treatment of psychiatric complications. Psychiatric disorders such as depression, anxiety and delirium occur in a signifcant percentage of cancer patients, particularly as disease advances and as cancer treatments become more aggressive. This paper reviews factors that can be utilized to identify patients who are at increased risk for developing psychiatric complications, such as those with advanced disease, certain cancer treatments, uncontrolled physical symptoms, functional limitations, lack of social support, and past history of psychiatric disorder. Methods of diagnostic assessment and strategies for managing depression, anxiety, delirium and suicidal ideation are also reviewed.Presented as an invited lecture at the 6th International Symposium: Supportive Care in Cancer, New Orleans, La., USA, 2–5 March 1994     

Panic disorder in primary care: Comorbid psychiatric disorders and their persistence

Objective

Although 70–80% of panic disorder patients use primary care to obtain mental health services, relatively few studies have examined panic patients in this setting. This study aimed to examine both the lifetime and current comorbid psychiatric disorders associated with panic disorder in primary care, the duration and severity of the disorder, and the sociodemographic factors associated with it.

Design

Patients were screened for panic disorder. Panic disorder and the comorbid disorders were determined using the Structured Clinical Interview for DSM-IV Axis I and II.

Setting

Eight different health care centers in primary care in the city of Espoo.

Subjects

Finnish-speaking, between 18 and 65 years of age.

Main outcome measures

Comorbid psychiatric disorders, the duration and severity of the disorder, and the sociodemographic factors.

Results

A sample of 49 panic disorder patients and 44 patients with no current psychiatric diagnosis were identified; 98% of panic disorder patients had at least one comorbid lifetime DSM-IV Axis I disorder. Major depressive disorder and other anxiety disorders were most common comorbid disorders. Lifetime alcohol use disorders also showed marked frequency. Interestingly, the remission rates of alcohol use disorders were notable. The panic symptoms appeared to persist for years. Panic disorder was associated with low education and relatively low probability of working full time.

Conclusions

Also in primary care panic disorder is comorbid, chronic, and disabling. It is important to recognize the comorbid disorders. High remission rates of comorbid alcohol use disorders encourage active treatment of patients also suffering from these disorders.Key Words: Comorbid disorders, Finland, general practice, panic disorder, primary careThere are only a few studies considering the comorbid psychiatric disorders associated with panic disorder in primary care and no earlier study had examined the prevalence of all other psychiatric disorders, both lifetime and current, using a structured diagnostic interview method.

• In this study 98% of panic disorder patients had at least one comorbid lifetime psychiatric disorder.
• Major depressive disorder, other anxiety disorders, and alcohol use disorders were the most common comorbid disorders.
• The panic symptoms appeared to persist for years.

     

Recognizing involuntary emotional expression disorder.

Involuntary crying or laughing are symptoms of a condition known as involuntary emotional expression disorder (IEED). This disorder is common among patients with stroke and other neurological disorders, such as multiple sclerosis, amyotrophic lateral sclerosis, and traumatic brain injury. Despite its prevalence, this condition is underrecognized and consequently undertreated in neurological settings. IEED can become disabling for patients who are not accurately diagnosed and treated. Differential diagnosis depends on recognition of the condition as an affective disorder and on its delineation from unipolar depression and other major psychiatric disorders. Clinical evaluation is essential for effective nursing care of this disorder. When the condition is found to be present, effective management must include education, pharmacological treatment, and teaching of self-care strategies. As patient advocates, neuroscience nurses are in a unique position to identify and assess such patients and to effectively guide patients and families in the management of this condition.