- Email: [email protected]
32.1 Somatic Symptom Disorders: Update on Diagnosis and Treatment
CLINICAL PERSPECTIVES 31.4 — 32.2
31.4 SPOTLIGHT ON WEB-BASED AND MOBILE APPLICATIONS USED BY ADOLESCENTS FOR ROMANTIC CONNECTION, WITH SPECIAL FOCUS ON LGBT YOUTH Owen S. Muir, MD, New York University, owenmuir@ gmail.com Objectives: By the end of this session, clinicians will be able to 1) identify which mobile and internet resources exist for social and romantic connections, their age “limitations,” their functionality, which resources are popular with adolescents, and the risks associated with them; and 2) identify special concerns for lesbian, gay, bisexual, and transgender (LGBT) patients and be familiar with technological options used by LGBT patients to connect, with an emphasis on those that put LGBT patients in a higher sexual risk category. Methods: A PowerPoint presentation will review the myriad options for social connection available to patients and romantic-specific sites for dating and “hooking up,” as well as an overview of mobile applications (apps) on which adolescent patients may participate. Furthermore, adolescent romance and dating norms will be examined in the context of these mobile tools, and LGBT-specific apps and cultural norms will be explored. Results: Adolescents are able to engage with a variety of online and mobile tools for connection and with the option of mis-statement of age, hooking up with others. From common websites, such as Facebook and Twitter, to more dating-specific sites, such as OKCupid, and mobile apps, such as Snapchat, What’s app, kik, and others, adolescents have a world of “private” or seemingly private communications with them at all times, as well as camera-equipped devices with which to document and share their lives. Furthermore, LGBT patients have gay- or lesbian-specific applications, such as Grindr for men who have sex with men with its 3.5 million users in 192 countries, that offer even more options in terms of meeting, dating, and even anonymous high-risk sex all at their disposal. Furthermore, one in five Grindr users between ages 18 and 24 years have never been tested for human immunodeficiency virus (HIV) in their lives and often report being HIV-negative instead of untested. In addition, there are positive online resources available to help the LGBT community. Conclusions: More specific knowledge of the digital culture in which our patients live and the specific apps and websites that allow these interactions will allow child psychiatrists to expertly interview their patients. Furthermore, cultural knowledge allows comprehensive assessments of all aspects of their social and romantic lives. Gay and lesbian students also have specific apps, culture, and risk factors that we need to be aware of to effectively evaluate this subgroup of potentially high-risk patients.
ADOL, HO, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.187
CLINICAL PERSPECTIVES 32 SOMATIC SYMPTOM DISORDERS: UPDATE ON DIAGNOSIS AND TREATMENT Daniel T. Williams, MD, Columbia University Medical Center, [email protected]; Kenneth Gorfinkle, PhD, Columbia University Medical Center, [email protected]; Boris Rubinstein, MD, MPH, Columbia University Medical Center, [email protected] Objectives: The workshop updates current clinical perspectives on the differential diagnosis, treatment, and management of somatic symptom disorders and malingering, as reformulated in DSM-5. Methods: Changes implemented in DSM-5 from the former DSM-IV diagnostic categories will be briefly reviewed. Treatment modalities for which there is supportive clinical evidence will be outlined, together with adjustments needed based on age and intellectual and educational levels of patients and parents. Evidence-based treatment studies will be noted. Video illustrations will be used. Opportunity for questions, as well as staff-participant interaction, will be provided. Results: Somatization is the tendency to use somatic metaphors to convey emotions that are difficult to express directly. Symptoms may be conveyed via
S48
www.jaacap.org
unconscious (somatoform) or conscious (factitious/malingering) channels. DSM-5 relieves the clinician from having to form a premature diagnostic distinction regarding this symptom. Review of relevant epidemiologic and neurophysiological studies can enhance clinical perspectives on the developmental course of these disorders, thus enhancing both diagnostic sophistication and treatment efficacy potential. Treatments for which substantial clinical experience and some controlled data do exist include CBT, familycentered and psychodynamic therapy, pharmacological treatment of comorbid conditions, and hypnosis for treating dissociative features in somatic symptom disorders. We will address these in some detail. Conclusions: Prognosis for these patients is influenced by the following: 1) the nature, chronicity, and severity of the underlying psychopathology; 2) the nature, chronicity, and severity of external stressors; 3) the intrinsic strengths of the patient; and 4) the effectiveness of the patient’s support system, including the comprehensiveness of treatment.
CON, SOM, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.189
32.1 SOMATIC SYMPTOM DISORDERS: UPDATE ON DIAGNOSIS AND TREATMENT Kenneth Gorfinkle, PhD, Columbia University Medical Center, [email protected] Objectives: A review and update of somatization disorders will delineate clinical challenges in evaluation and treatment of individuals with factitious disorders, malingering, and psychological factors affecting medical conditions. Methods: Special emphasis will be given to the role of anxiety and cognitive overload in the diagnosis and treatment of type 1 and type 2 diabetes. Results: Clinical criteria for assessment of factitious disorders and malingering will be reviewed in the context of phobic avoidance of hypoglycemia and insulin restriction in service of weight loss (diabulima). Cognitive-behavioral approaches to diagnosis and assessment will be reviewed.
CON, SOM, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.815
32.2 TRAVERSING THE MINEFIELD: SOMATIZATION IN THE CONSULTATION/LIAISON SERVICE Boris Rubinstein, MD, MPH, Columbia University, br10@cumc. columbia.edu Objectives: Children presenting with physical symptoms, without a defined cause, present a particular challenge for pediatricians and child and adolescent psychiatrists. Child psychiatrists are usually not adept at assessing physical complaints, and pediatricians usually are not comfortable interviewing children with mental health problems and often do not know what questions to ask or how to ask them. In addition, pediatricians, especially those without much experience such as residents, are often exasperated and put off by children and adolescents presenting with somatic symptom disorders. These cases, often seen by the consultation and liaison (C/L) service, present a challenge for the C/L psychiatrist as she/he walks a minefield among patients, parents, and the medical team, serving different roles as consultant, educator, therapist, collaborator, and manager for all of them. Methods: By use of clinical vignettes and a review of the literature, we will examine the role of the C/L psychiatrist and review different approaches in the treatment and management of this difficult clinical problem. Results: The C/L psychiatrist often works under severe time constraints, having to arrive at a diagnosis and present a treatment plan before the patient is discharged. Management of these cases requires that the child psychiatrist understands that she/he is dealing with different cultures with different needs and expectations. She/he needs to clearly define their role as consultant, determine who is or are the patients, and develop a treatment plan that is feasible considering the patient’s developmental level, biological vulnerabilities, the family’s strengths and weaknesses, and the resources available in the community. Conclusions: Managing children with somatoform disorders can be a most difficult situation that challenges even the most experienced clinicians. Developing a good working relationship with the pediatric team, avoiding
J OURNAL
OF THE
AMERICAN A CADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
31.4 SPOTLIGHT ON WEB-BASED AND MOBILE APPLICATIONS USED BY ADOLESCENTS FOR ROMANTIC CONNECTION, WITH SPECIAL FOCUS ON LGBT YOUTH Owen S. Muir, MD, New York University, owenmuir@ gmail.com Objectives: By the end of this session, clinicians will be able to 1) identify which mobile and internet resources exist for social and romantic connections, their age “limitations,” their functionality, which resources are popular with adolescents, and the risks associated with them; and 2) identify special concerns for lesbian, gay, bisexual, and transgender (LGBT) patients and be familiar with technological options used by LGBT patients to connect, with an emphasis on those that put LGBT patients in a higher sexual risk category. Methods: A PowerPoint presentation will review the myriad options for social connection available to patients and romantic-specific sites for dating and “hooking up,” as well as an overview of mobile applications (apps) on which adolescent patients may participate. Furthermore, adolescent romance and dating norms will be examined in the context of these mobile tools, and LGBT-specific apps and cultural norms will be explored. Results: Adolescents are able to engage with a variety of online and mobile tools for connection and with the option of mis-statement of age, hooking up with others. From common websites, such as Facebook and Twitter, to more dating-specific sites, such as OKCupid, and mobile apps, such as Snapchat, What’s app, kik, and others, adolescents have a world of “private” or seemingly private communications with them at all times, as well as camera-equipped devices with which to document and share their lives. Furthermore, LGBT patients have gay- or lesbian-specific applications, such as Grindr for men who have sex with men with its 3.5 million users in 192 countries, that offer even more options in terms of meeting, dating, and even anonymous high-risk sex all at their disposal. Furthermore, one in five Grindr users between ages 18 and 24 years have never been tested for human immunodeficiency virus (HIV) in their lives and often report being HIV-negative instead of untested. In addition, there are positive online resources available to help the LGBT community. Conclusions: More specific knowledge of the digital culture in which our patients live and the specific apps and websites that allow these interactions will allow child psychiatrists to expertly interview their patients. Furthermore, cultural knowledge allows comprehensive assessments of all aspects of their social and romantic lives. Gay and lesbian students also have specific apps, culture, and risk factors that we need to be aware of to effectively evaluate this subgroup of potentially high-risk patients.
ADOL, HO, SEX http://dx.doi.org/10.1016/j.jaac.2017.07.187
CLINICAL PERSPECTIVES 32 SOMATIC SYMPTOM DISORDERS: UPDATE ON DIAGNOSIS AND TREATMENT Daniel T. Williams, MD, Columbia University Medical Center, [email protected]; Kenneth Gorfinkle, PhD, Columbia University Medical Center, [email protected]; Boris Rubinstein, MD, MPH, Columbia University Medical Center, [email protected] Objectives: The workshop updates current clinical perspectives on the differential diagnosis, treatment, and management of somatic symptom disorders and malingering, as reformulated in DSM-5. Methods: Changes implemented in DSM-5 from the former DSM-IV diagnostic categories will be briefly reviewed. Treatment modalities for which there is supportive clinical evidence will be outlined, together with adjustments needed based on age and intellectual and educational levels of patients and parents. Evidence-based treatment studies will be noted. Video illustrations will be used. Opportunity for questions, as well as staff-participant interaction, will be provided. Results: Somatization is the tendency to use somatic metaphors to convey emotions that are difficult to express directly. Symptoms may be conveyed via
S48
www.jaacap.org
unconscious (somatoform) or conscious (factitious/malingering) channels. DSM-5 relieves the clinician from having to form a premature diagnostic distinction regarding this symptom. Review of relevant epidemiologic and neurophysiological studies can enhance clinical perspectives on the developmental course of these disorders, thus enhancing both diagnostic sophistication and treatment efficacy potential. Treatments for which substantial clinical experience and some controlled data do exist include CBT, familycentered and psychodynamic therapy, pharmacological treatment of comorbid conditions, and hypnosis for treating dissociative features in somatic symptom disorders. We will address these in some detail. Conclusions: Prognosis for these patients is influenced by the following: 1) the nature, chronicity, and severity of the underlying psychopathology; 2) the nature, chronicity, and severity of external stressors; 3) the intrinsic strengths of the patient; and 4) the effectiveness of the patient’s support system, including the comprehensiveness of treatment.
CON, SOM, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.189
32.1 SOMATIC SYMPTOM DISORDERS: UPDATE ON DIAGNOSIS AND TREATMENT Kenneth Gorfinkle, PhD, Columbia University Medical Center, [email protected] Objectives: A review and update of somatization disorders will delineate clinical challenges in evaluation and treatment of individuals with factitious disorders, malingering, and psychological factors affecting medical conditions. Methods: Special emphasis will be given to the role of anxiety and cognitive overload in the diagnosis and treatment of type 1 and type 2 diabetes. Results: Clinical criteria for assessment of factitious disorders and malingering will be reviewed in the context of phobic avoidance of hypoglycemia and insulin restriction in service of weight loss (diabulima). Cognitive-behavioral approaches to diagnosis and assessment will be reviewed.
CON, SOM, TREAT http://dx.doi.org/10.1016/j.jaac.2017.07.815
32.2 TRAVERSING THE MINEFIELD: SOMATIZATION IN THE CONSULTATION/LIAISON SERVICE Boris Rubinstein, MD, MPH, Columbia University, br10@cumc. columbia.edu Objectives: Children presenting with physical symptoms, without a defined cause, present a particular challenge for pediatricians and child and adolescent psychiatrists. Child psychiatrists are usually not adept at assessing physical complaints, and pediatricians usually are not comfortable interviewing children with mental health problems and often do not know what questions to ask or how to ask them. In addition, pediatricians, especially those without much experience such as residents, are often exasperated and put off by children and adolescents presenting with somatic symptom disorders. These cases, often seen by the consultation and liaison (C/L) service, present a challenge for the C/L psychiatrist as she/he walks a minefield among patients, parents, and the medical team, serving different roles as consultant, educator, therapist, collaborator, and manager for all of them. Methods: By use of clinical vignettes and a review of the literature, we will examine the role of the C/L psychiatrist and review different approaches in the treatment and management of this difficult clinical problem. Results: The C/L psychiatrist often works under severe time constraints, having to arrive at a diagnosis and present a treatment plan before the patient is discharged. Management of these cases requires that the child psychiatrist understands that she/he is dealing with different cultures with different needs and expectations. She/he needs to clearly define their role as consultant, determine who is or are the patients, and develop a treatment plan that is feasible considering the patient’s developmental level, biological vulnerabilities, the family’s strengths and weaknesses, and the resources available in the community. Conclusions: Managing children with somatoform disorders can be a most difficult situation that challenges even the most experienced clinicians. Developing a good working relationship with the pediatric team, avoiding
J OURNAL
OF THE
AMERICAN A CADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017