Behavioral science - Somatoform disorders

Question 1

Condition: Conscious production of a physical symptom with unconscious motivations (e.g. : patient wants to assume the “sick” role, but for unrecognized reasons)

Answer 1

Factitious disorder

Question 2

What are the 5 types of somatoform disorders listed in the DSM5?

Answer 2

Somatization disorder (now Somatic symptom disorder)
Conversion disorder
Body dysmorphic disorder (BDD)
Factitious disorder
Malingering
Illness anxiety disorder - replacement for hypochondriasis (DSM IV only)

Pain disorder (DSM IV only, removed in 5)

Question 3

What is malingering?

Answer 3

physical symptoms that are consciously produced for conscious motivations (e.g. patient wants to avoid legal, work, or school responsibilities or obtain money)

Question 4

How is somatization utilized as a defense mechanism?

Answer 4

unconscious expression of an unacceptable emotion as a physical symptom to avoid dealing with that emotion

e.g. You’re unhappy/depressed but instead of addressing it you subconsciously channel the negative feelings into a physical manifestation of chronic pain

Question 5

Primary gain is motivated by:

Secondary gain is motivated by:

Answer 5

internal/psychic motivations

gaining attention, money, drugs, avoiding responsibility. “I cannot care for myself so you have to.”

Question 6

Pt. manifests physical illness to draw parents attention away from sibling (to feel like the favorite child)

What type of motivation is this (internal or external)? What type of gain?

Answer 6

External

Secondary gain

Question 7

When do somatoform disorders usually develop?

Answer 7

Tend to start in early adulthood but reoccur with stress

Question 8

Who are more affected by somatoform disorders, women or men?

Answer 8

women usually more affected but equal among hypochondriacs

Question 9

50% of patients with somatoform disorders have co-morbid mental illness. What are two most common?

Answer 9

usually depression/anxiety

Question 10

T/F somatoform disorders cause impairment in social and/or occupational function

Answer 10

true

Question 11

T/F Somatization disorder, hypochondriasis, and pain disorder tend to run in families

Answer 11

True

Question 12

family history of mood disorder or obsessive-compulsive disorder are associated with increased incidence of which two somatoform disorders?

Answer 12

hypochondriasis

pain disorder

Question 13

somatization disorder incidence is increased in patients with a family history of ______ and ______

Answer 13

antisocial personality disorder and alcoholism

Question 14

What genetic underpinnings in which neurotransmitter pathways are implicated in development of somatization disorder, hypochondriasis, and pain disorder?

Answer 14

serotonin-related gene pathways (specifically serotonergic hypofunction)

Question 15

What disorder does this describe?

• ≥4 pain issues
  2 gastrointestinal,
  1 sexual,
  1 neurological symptom
  (none can be explained medically)
• Onset before 30
• Symptoms tend to be chronic and complete remission is rare
• Unconscious, no secondary gain, patient unaware of behaviors and symptom generation
• causes impairment in social /occupational function

Answer 15

Somatization disorder DSM-IV only (somatic symptom disorder in DSM5)

E.g.

Pain: headache
GI: nausea + heartburn
Sexual: menstrual irregularities
Pseudoneurological: loss of sensation
Symptoms may vary by culture

Question 16

What disorder does this describe?

Sudden and dramatic loss of one or more voluntary motor and/or sensory functions suggesting a neurologic etiology

Preceded by psychological stress or conflict – the presenting symptom tends to have a symbolic relationship with the stressor and serves to decrease anxiety associated with it

• Unconscious, no secondary gain, patient aware of loss and symptom generation
• causes impairment in social /occupational function

Answer 16

Conversion disorder

Question 17

What is the time course of a conversion disorder? Who is most susceptable to developing one?

Answer 17

Usually self-limited with remission in

Question 18

These are examples of what disorder?

Seeing something violent = blindness
Shooting someone in self defense = right arm paralysis

Answer 18

Conversion disorder

Question 19

T/F Course of conversion disorder may be shortened with hypnosis, drug-assisted interviewing

Answer 19

True

Question 20

What is “La belle indifference” with regard to conversion disorder?

Answer 20

Common feature of condition where patient seems uncaring/unconcerned about their remarkable symptoms

Question 21

Clinical signs of conversion disorder manifestations:

Answer 21

Wrong dermatomes for sensory loss
Blindness still has optokinetic effects
During seizure can sneeze or react to pain
Pain radiates down instead of up
Seizure head movements are vertical, not horizontal

Shifting paralysis
Globus hystericus - pathognomonic (lump in my throat)
Pseudoseizures

Patients are not pretending - unaware they are generating their physical symptoms

Question 22

What disorder does this describe?

Fear or idea of having a serious medical illness based on misinterpretation of bodily symptoms

Persists despite negative findings and reassurance after medical work ups

Symptoms persist for ≥6 months

• Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
• causes impairment in social /occupational function

Answer 22

Hypochondriasis (DSM IV only)

Renamed “Illness anxiety disorder” (DSM V)

Question 23

What differentiates “Illness anxiety disorder” vs “Somatic symptom disorder” in DSM5?

Answer 23

Illness anxiety disorder = high health anxiety without somatic symptoms

Somatic symptom disorder has worry + somatic symptoms

Question 24

T/F Hypochondriasis/Illness anxiety disorder may have a similar etiology to OCD, GAD and the impulse control disorders – SSRIs may help

Answer 24

True

Question 25

What disorder does this describe?

Preoccupation with an imagined problem or insignificant abnormality in appearance – usually involving the face or head

Not be accounted for by an eating disorder

Plastic surgery or medical interventions rarely relieve symptoms but are commonplace

• Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried
• causes impairment in social /occupational function

Answer 25

Body Dysmorphic Disorder(BDD)

Nose too big/crooked, breasts /body not symmetrical, muscles not symmetrical, too small (adonis complex)

Question 26

Help me, Mary. You’re my only hope….

Answer 26

Schwartz says: Anorexics are “body dysmorphic” thinking they are overweight

?Does this mean anorexics do or do not have BDD?

Question 27

What are the criteria for Pain Disorder (DSM IV only)

Answer 27

Protracted pain that is severe enough to cause the patient to seek medical attention

Cannot be explained by physical causes

Acute (

Question 28

T/F Pain disorder may be related to real but minor medical problem

Answer 28

true

Question 29

Prior to diagnosis pain disorder, conversion disorder, body dysmorphic disorder, hypochondriasis (Illness anxiety disorder), somatization disorder (Somatic symptom disorder) what should be ruled out?

Answer 29

Unidentified organic illness!

Globus hystericus (cranial nerve disorders), severe neurological pain (spinal arachnoiditis, spinal whiplash), early-stage CT disorders (SLE, RA), CNS (tumors, MS, epilepsy, dementia, stroke), myasthenia gravis, endocrine (hypoglycemia, thyroid abnormalities, porphyria), chronic fatigue syndrome, fibromyalgia

Question 30

Management for somatoform disorders:

Answer 30

frequent visits (regular, short appts, reassurance,empathy)
identify stressors and motivations for primary gain
treat co-morbid depression / anxiety
Allow face saving opportunities
Refer for non-invasive physical or occupational therapy

Question 31

T/F SSRIs have been shown to be effective in treatment of hypochondriasis, body dysmorphic disorder, and pain disorder

Answer 31

true

Question 32

T/F Drug-assisted interviewing with sodium amobarbital or hypnosis may be of help with conversion disorder

Answer 32

true

Question 33

T/F Psychotherapy, hypnosis, and, interpersonal and cognitive behavioral therapy may be helpful for somatoform disorders

Answer 33

true

Question 34

Formerly known as Münchausen syndrome

Answer 34

Factitious Disorder

Münchausen syndrome ‘by Proxy’ if you create medical problems in others…

Question 35

Is factitious disorder a true somatic disorder?

Answer 35

unknown

Question 36

What is Factitious Disorder?

Answer 36

Conscious feigning or production of physical or mental illness (motivation for behavior is unconscious..)

Get angry and leave quickly when confronted

Motivation is often in order to receive attention from medical personnel – to assume the “sick” role

primary gain = to feel safe and cared for

possible secondary gain = to feel proud, an expert, able to figure things out that doctors cannot

Tends to have a negative impact on work, school, and/or social functioning

Question 37

T/F Factitious disorder is more common in people who work in the medical field

Answer 37

true

Question 38

Commonly Feigned or Produced Signs and Symptoms in Factitious Disorder

Answer 38

Abdominal pain (a “grid abdomen” may signify previous unnecessary surgical procedures- this happens with somatic pain disorder too)
Fever (heating a thermometer)
Hematuria (blood from a needle stick)
Seizures (taking excess caffeine, theophylline)
Skin lesions (easily reached areas by chemical dermatitis)
Tachycardia (drug-induced)
Hypoglycemia (insulin injection – look for increased insulin but low C-peptide)
Fever (inject feces)
Deep vein thrombosis (use ligature)

Question 39

Parent uses chemical to cause skin rash on their child then takes them to the doctor. What disorder is this?

Answer 39

Factitious disorder by proxy is when someone creates medical problems in others.

Typically child abuse.

Must be reported

Question 40

What is usually the motivation behind factitious disorder by proxy?

Answer 40

gaining attention

parent may have a history of childhood abuse/neglect or serious childhood illness during which he or she felt cared for and protected by medical personnel

Or may like being the expert in his/her child’s care

Question 41

What is this describing?

Conscious simulation or exaggeration of physical or mental illness to achieve some sort of secondary gain

(Disability, Drugs in the ER, Leave of absence)

Symptoms improve as soon as the secondary gain is obtained
Seen more frequently in the incarcerated and people involved in lawsuits

Answer 41

Malingering (DSM IV only)

Question 42

T/F Malingering is a psychiatric illness

Answer 42

False

Question 43

Conscious or not-conscious of producing physical symptoms?

Somatoform Disorders, Factitious Disorders, and Malingering

Answer 43

Not-conscious : Somatoform Disorders

Conscious : Factitious Disorders, and Malingering

Question 44

Best treatment for somatic-type disorders?

Answer 44

simplify the number of providers, medications, procedures