Factitious disorder and malingering DSA and CIS Flashcards
Somatic Symptom & Related Disorders
A group of illnesses characterized by physical symptoms and possible distress that are highly inconsistent with medical workup.
Quite common but mainly undiagnosed
30% of Primary Care pts present with unexplained sxms
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder
(Functional Neurological Symptom Disorder)
Somatic Symptom Disorder
One or more somatic symptoms that are distressing or disruptive
Excessive thoughts, feelings, or behaviors related to it
Persistent thoughts about seriousness
Persistently high anxiety about health
Excessive time and energy devoted to sxms
Persistence is defined as at least 6 months
Health concerns override all other concerns
Modest abnormalities are perceived as signs of serious underlying pathology
Are not reassured for long. Leads to lots of utilization of care
Preoccupation with symptoms starts early and often spans many years
Illness Anxiety Disorder
Preoccupation with having serious disease
Essentially there is no somatic sxm
Normal bodily functions are misinterpreted
Easily alarmed about health status.
Tend not to be reassured
Excessive health related behaviors or avoidance
Duration 6 months or greater
Illness Anxiety Disorder
epidemiology
Prevalence: 1 - 10%
Lots of doctor shopping, lots of checking behavoir
Middle to older age but may occur at any age
M:F ratio is 1:1
Prognosis: fair to good
Somatic Symptom & Illness Anxiety - Management
May remit / improve with resolution of life stressors
Legitimize suffering
Protect from iatrogenic harm
Reinforce physician relationship without sxms
Best managed in a primary care setting
Meds for comorbid psych disorders in SSD
SSRIs likely to be effective in IAD
CBT helpful in IAD
Conversion Disorder/Diagnosis
An illness of voluntary motor or sensory symptoms.
Symptom not intentionally produced (unconscious)
Clinical findings are incompatible with recognized med/neuro conditions
Conversion Disorder
stats
Often monosymptomatic/acute
Highly prevalent in hosp, esp neuro wards
M:F ratio ~ 1:5
Prognosis very good
Unconscious factors
Conversion Disorder presentations
Majority have coexisting neurological disorder
Epilepsy, stroke, tumor
Conforms to pt’s understanding of disease, not physiology
Often shows la belle indifference
Conversion Disorder Management
Spontaneous remission common for acute presentation
Frequently responds to suggestion/hypnosis, benzos
Note: benzos are for short term management
May respond to short-term focused therapy
Persistent presentations respond well to behavior mod
Factitious Disorder- types
Factitious Disorder Imposed on Self
Factitious Disorder Imposed on Another
Munchausen’s by Proxy
Factitious Disorders
- basics
Voluntary (conscious) production or reporting of signs, symptoms, diseases
Primary goal is to obtain role of patient
- Care and attention
- This is called Primary Gain
Conscious effort, unconscious motivation
Factitious Disorder
Physical/Psychological Symptoms
Typically socially conforming young females
Higher socioeconomic class
Intelligent, educated, employed in medically
related field
Usually associated with personality disorder
Thought that most cases are never discovered
Factitious Disorder Variant
Munchausen’s
Triad of:
Fabrication of disease
Ever-shifting complaints
intense frequenting of different hospitals
Typically men of lower socioeconomic class
Socially maladjusted
Average age of 30
Factitious Disorder Imposed on Another
Munchausen’s By Proxy
Signs/symptoms created in another
Usually a child or elderly person
Perpetrators were mothers/daughters in almost all cases
Factitious Disorder
Common Symptoms/Diseases
Intestinal bleeding
Hematuria
Fever
Diarrhea
Hypoglycemia
Cancer
Non-epileptic seizures
Iron deficiency anemia
Renal stones
Factitious Disorder - Management
Consider patient rights/informed consent
Confrontation by both primary physician/psychiatrist
Emphasize degree of emotional distress
Emphasize behavior must reflect difficulty in
communicating needs
Prognosis poor for Munchausen’s
Malingering
Intentional production of illness
Motivated by external incentives (Secondary Gains):
- Financial
- Avoiding military service - Avoiding criminal prosecution - Obtaining controlled substances - Obtain Shelter
Vast majority are male
Medicolegal presentation
Marked disparity between disability/
objective findings
Lack of cooperation with evaluation/treatment
Associated with Antisocial personality disorder
MMPI or Millon helpful
Malingering
Management
Best Treatment is not established
Confrontation?
Go along with the act?
What’s the harm?!
Breaking down mechanisms and motivations
Somatic Sxm/ IAD/ conversion- unconscious mechanism, unconscious motivation
factitious- conscious mechanism, unconscious motivation
malingering- conscious mechanism, conscious motivation
gal presents with dysuria a billion times, labs neg
you find out she put blood in the next sample. what’s the ddx?
Malingering or Factitious disorder
gal faking blood in urine has no real reason to do it and no requests from you. Now what is the dx? Recommended treatment?
factitious disorder
Supportive therapy
guy in car accident legs not working, seems not bothered by it. EMGs are normal. What’s the idea?
likely Conversion disorder
tied to trauma
What is true about conversion disorder? Patients rarely recover More common in patients from urban areas It is more frequent in men In men, it is most common in combat veterans It is more common in higher SES
In men, it is most common in combat veterans
high rate of successful treatment
more common in rural settings
Which statement is true of conversion disorder:
The mechanism of illness production is conscious, but not the motivation
The motivation for illness is conscious, but not the mechanism
Both the mechanism of illness production and motivation are conscious
The mechanism and motivation are unconscious
The mechanism and motivation are unconscious
Which plans might be considered for conversion disorder:
SSRIs, Atypical A/Ps, Benzos
Atypical A/Ps, Benzos, Relaxational Therapy
Reassurance, Relaxational Therapy, Do Nothing
Relaxational Therapy, Do Nothing, or SSRIs
Reassurance, Relaxational Therapy, Do Nothing
cable tech guy worried about colon cancer, spent half a year trying to figure it out
upset stomach, butteflies, diarrhea, loose stoolse twice in last month
grandfather had GI cancer
dx?
illness anxiety disorder
what should we do with this guy who gets terrible illness anxiety disorder when his wife is pregnant?
Reassure and have 3 way call w/ PCP
try to not treat with medications/ invasive tests.
mom brings kid to pediatric GI practice with vague timeline, abdominal pain and diarrhea
scars as from exploratory laparoscopy are there but the mom says the records are not important
what’s your suspicion?
Factitious disorder
interview the child separately
college student obsessed with needing plastic surgery for chin
(not important)
body dysmorphic disorder
unconscious mechanism and unconscious motivation
SSRIs can be used here, consider low dose anti-psychotics
guy says he’s going to kill himself, upset over girlfriend breaking up with him
no thought disorder, not responding to internal stimuli
full range of affect
4 past psych hosps. 3 suicide attempts, 2 via wrist cut, 1 via OD.
you offer antipsychotics. says he’s allergic. He says Xanax helps.
Later, you notice him engaged in witty banter with an attractive female staff member. When you return to discuss discharge to shelter, he is afraid he will succumb to the pressure of the voices and kill himself if allowed to leave.
dx: malingering
all possible next steps:
Give alprazolam, admit for danger to self
Tell him to call GF and ask for another chance
Don’t give alprazolam, then discharge to shelter
Order risperidone, then wait and see what happens
A quickly tilting planet
The view on controlled substances is changing quickly.
Now opiates, benzos next, then stimulants
Your role in your patient’s substance misuse will be scrutinized both in court and by the Medical Board.
You will need to show active efforts to combat substance use disorders.
The PDMP is your friend.
