Factitious Disorders

Question 1

Background of psychological arm illness

Answer 1

personal and cultural interpretation of symptoms and events

person’s thoughts, emotions, beliefs, behaviors and circumstances are as important or even more important than pathophysiology in determining symptom intensity and disability

various behaviours to deal with the effect of the illness or the injury

take time to consider advises and give time to the patient to think about the whole situation - no pressure

it is necessary to improve health and wellness thoughts, emotions and behaviours in response to the symptoms

Question 2

Psychology

Answer 2

our mind can play tricks to us!!!

mind can overreact to a pain sensations that is not dangerous

often people who believe what they feel even in light of real facts

Question 3

Affect

Answer 3

affect amplifies or buffers the impact of disease and impairment

affect:

depression, anxiety, heightened illness concerns), life stress (stress, stage of life, financial distress)

Question 4

coping strategies

Answer 4

strategies the affect how we deal with symptoms, illness or impairment

different coping strategies - “I will be fine!” positive - “Catastrophizing” negative

catastrophic thinking leads to greater symptoms and limitations and delayed return to work

extreme form of this aspect is “somatoform disorders” - very great negative coping effect - heightened illness concern (not use hypochondriasis - stigma!!!)

Question 5

pain

Answer 5

pain wired to provide a signal of trouble (fight or flight system)

psychological traits are important - pain may exacerbate depressive symptoms or become a somatic focus

patients with greater symptoms of anxiety or depression experience more pain with cts and after surgery or trauma

Question 6

measuring psychological aspects of illness

Answer 6

Depression:

Depression subscale of the patient health questionnaire (PHQ)

catastrophic thinking:

Pain catastrophizing scale (PCS)

Heightened illness concern:

Health anxiety inventory, whitley index, somatic symptoms inventory

Question 7

secondary gain and malingering

Answer 7

secondary gain maybe the reason for perpetuated symptoms and disability.

current theories emphasize secondary gain in terms a social learning model where environmental reinforce chronicity

in contrast is malingering where a patient pretend to be sick or exaggerates a condition in order to gain a particular objective

there is a continuum between secondary gain and malingering

Question 8

Fatitous Lymphedema

Answer 8

painless swelling and denial of any knowledge of the cause

“broken window pattern” distal to the site of tourniquet

attributed to occupational activities

defined point from the shoulder to distal - not always is a history of tourniquet recognizable

splinting over night

carefully talk to the patient to bring him to a Psychiatric

Question 9

Factitious ulceration

Answer 9

history of trivial trauma

wounds do not heal because of the manipulation of the patient

splinting over night is the best therapy

maybe some patients can manipulate the wounds with a wire or something else

Question 10

dysfunctional postures

Answer 10

claimed inability to use the hand

classic position is the clenched fist

3 ulnar fingers are in a flexed position while thumb and index finger are usually can be used normal

different and various postures are known!!!

pain while examination the patient

maybe the patient should be observed at night with a camera

Question 11

self-cutting

Answer 11

lacerations are usually longitudinal or oblique,

often with borderline patiens, which is a condition characterized by difficulty with affect regulation and self-soothing

Question 12

secretan syndrome

Answer 12

result of a patient who repeatedly striking the dorsum of the hand with swelling initially and later a pertendonous fibrosis of the extendor tendons

combination of secondary gain and conversion reaction

Question 13

Munchausen syndrome

Answer 13

histoy of many illnesses with many operations - tend to go from one medical facility to another - know everything about the disease

if there deception is realized they go to the next doctor

Question 14

somatomform disorders

Answer 14

characterized by physical symptoms that suggest a medical condition in the absence of pathophysiology or another mental disorder that accounts for the symptoms

Question 15

pain disorder

Answer 15

pain is the predominant focus

pain causes substantial disability and distress

predominant etiology is felt to be psychological

Question 16

somatization disorders

Answer 16

unexplained somatic symptoms in addition to pain

pruritus, nausea, numbness

full criteria:

4 pain symptoms

2 gastrointestinal symptoms

1 sexual symptom

1 neurological symptom

common among patients with chronic pain

excessive attention to internal stimuli (“sensory amplification”) combined with a denial of psychological or interpersonal difficulties

Question 17

conversion disorder

Answer 17

motor or sensory defect cannot explained by pathophysiology, psychological factors are judged to be associated with such symptoms

symptoms are not intentionally produced or feigned

classification
motor, sensory, epileptiform or mixed

for example: patient with sudden onset of arm weakness or inability to lift the hand

Question 18

hypochondriasis

Answer 18

idea of having a serous disease

duration of more than 6 month with symptoms that are not better accounted for by other psychological disorders such as obsessive-compulsive disorder, pain disorder or generalized anxiety disorder

Question 19

non-specific illness

Answer 19

challenge for health care providers, catastrophic thinking,

physician can trapp into the patient’s catastrophic thinking - “stress contagion” - feelings like eagerness (Eifer), restlessness or even desperation

numbers of diagnoses and treatments without improving health or wellness

biopsychological framework - physicians have to learn to step back, embrace the limitations of modern medicine - both pathophysiological and psychological

recognition of factitious disorders, somatization disorders and the influence of distress on pain intensity and disability

such as illness construction:

writer’s cramp, cumulative trauma disorder, occupational overuse syndrome, work-related upper limb disorder

Question 20

Recogizing factitious illness and avoiding mistaken diagnosis

Answer 20

warning signs:

1. seeking treatment at many health facilities without a clear diagnosis after multiple tests and operations
2. severe symptoms that are not consistent with what seems to be a minor incident or injury
3. multiple wounds or scars
4. symptoms of swelling and stiffness, that are reported to be changing and worsening without apparent cause
5. a desire and willingness for further testing and treatment that has little, if any, justification

often mistreated CRPS Type I, no resolving of symptoms, the disease stays, developing of a nocebo-effect

Question 21

Management of patients with factitious disorders

Answer 21

patients have a need to be injured or disabled, usually without seeking financial gain

mostly personality disorders or try to get attention at home (parents, spouse or family members)

difficult to treat - requires a high level of trust and frequently family support

surgeons are most effective, see themselves as part of a larger team that can ensure we take advantage of all opportunities to get and stay healthy

human experience of symptoms and disease is a product of the normal function of the human mind, filtered by circumstances, mindset and stress - cultivate good communication skills and learn to be cautious with tests, treatments, hand health advice, keeping all options for health and wellness in mind