Final Somatoform disorders

Question 1

What is primary gain

Answer 1

Not doing it for conscious gain; unconscious motivation

Ex: somatiform disorders (somatization, conversion, hypochondriasis, body dysmorphic) and factitious disorders

Question 2

What is secondary gain?

Answer 2

Malingering – not a psych disorder; intentional desire for gain/reward

Question 3

Definition: somatoform disorders

Answer 3

Physical sx which suggest a GMC but not fully explained by GMC, direct effects of a substance or another mental disorder

Sx cause clinically significant distress or impairment in functioning

Question 4

DSM-IV criteria for somatization disorder

Answer 4

a) Many physical complaints beginning BEFORE AGE 30, and occur over SEVERAL YEARS and result in TX SOUGHT or sig IMPAIRMENT in functioning

b) Physical complaints include:
FOUR pain 
TWO GI
ONE sexual
ONE pseudoneurological sx

c) Either (1) or (2)
(1) After investigation, sx cannot be explained
(2) When related to GMC, sx appear out of proportion

d) sx NOT INTENTIONALLY produced or feigned (as in factitious or malingering)

Question 5

Background/aspects of somatization

Answer 5

Colorful and exaggerated complaints, lack of facts
Inconsistent histories (review med records)
Tx sought from multiple providers
Multiple meds, exams, dx procedures, surgeries and hospitalizations
Co existing depression/anxiety/substance abuse disorders/ Personality disorders

Question 6

Tx of Somatization disorder

Answer 6

a) Understand physical complaints reflect emotional issues
b) Psychotherapy
c) Meds for concurrent psychiatric disorders
d) Avoid unnecessary meds and procedures
e) Regularly scheduled provider visits

Question 7

DSM IV dx of conversion Disorder

Answer 7

A) at least 1 sx or deficit affecting voluntary motor or sensory function that suggest a neuro condition or GMC

B) psych factors a/w sx or deficit bc initiation/exacerbation of sx is PROCEEDED by conflicts/stressors

C) sx or deficit is NOT INTENTIONALLY produced or feigned (as in factiious or malingering)

D) sx not explained by GMC, substance or cultural behavior

E) sx results in distress or impairment

F) sx not limited to pain or sexual dysfunction and is not better accounted for by another mental disorder

Question 8

H&P conversion disorder

Answer 8

Sx and PE usually inconsistent
Neuro exam NORMAL
*be sure no underlying neuro etiology prior to making this dx
May show LA BELLE INDIFFERENCE
Co existing depression, anxiety, dissociative disorders and personality disorders can occur

Question 9

Tx of conversion disorder

Answer 9

Sx last days to wks
Sx tend to remit spontaneously
Supportive, insight oriented psychotherapy or behavioral therapy can facilitate recovery
Can use anxiolytics and relaxation techniques if appropriate

Question 10

Etiology of sx a/w conversion disorder

Answer 10

Sx represent “symbolic resolution of unconscious psych conflict reducing anxiety and serving to keep the conflict out of mind”

Sx most commonly sensory deficits (blind, numb), motor deficits (paralysis, mutism) and or psychogenic non-epileptic seizures “pseudoseizures”

Sx usually conform to what the pt thinks… not anatomical or physiologic principles

Question 11

DSM-IV criteria of hypochondriasis

Answer 11

A) Preoccupation w/ fears of having or the idea that one has a SERIOUS DZ based on misinterpretation of bodily sx

B) Preoccupation persists despite appropriate medical evaluation and reassurance

C) Belief in criterion A is not of delusional intensity and is NOT restricted to a circumscribed concern about appearance (ie Body dysmorphic disorder)

D) preoccupation results in distress/impairment

E) at least 6 mth

F) Preoccupation not better accounted for by another mental disorder (GAD, OCD, Panic d/o, MDD, separation anxiety or another somatoform disorder)

Question 12

Tx of Hypochondriasis

Answer 12

• Best tx with reassurance and regular office visits
• Avoid unnecessary dx procedures and meds
• Individual or group therapy

Question 13

Etiology/background of Hypochondriasis

Answer 13

Often a/w serious illnesses in childhood or a family member

• Usually chronic, waxing and waning
• Multiple vague, ambiguous or exaggerated complaints w/o physical basis
• Normal evaluations but complications can result from dx testing/procedures
• Doctor shopping is common

Question 14

DSM IV criteria of Body Dysmorphic disorder

Answer 14

A) Preoccupation with imagined defect in appearance
B) Causes distress or impairment
C) Preoccupation is not better accounted for by another mental d/o

Question 15

Tx of Body Dysmorphic Disorder

Answer 15

(poor prognosis)

• often pursue and receive med/surgical tx but should AVOID
• Behavior modification and therapy
• Antidepressants may be effective

(neuroleptics??)

Question 16

DSM IV criteria Factitious Disorder

Answer 16

A) Intentional production or feigning of physical or psychological s/sx
B) Motivation is to assume the sick role
C) External incentives for the behavior (as in malingering) are absent

Question 17

What is Munchausen’s syndrome

Answer 17

Most severe and chronic form of Factitious disorder (munchausen’s syndrome by proxy)
*consists of recurrent hospitalization, traveling to multiple locations (preregrination), pathological lying in a manner intriguing to the listener (pseudologia fantastica or mythological ??)

Question 18

DX factitious disorder NOS

Answer 18

Factitious sx that do not meet criteria (factitious disorder by proxy)

Question 19

Tx of Factitious disorder

Answer 19

No specific tx, prognosis generally poor, goal is to recognize the disorder early and prevent unnecessary medical tx

Question 20

Features of Malingering

Answer 20

INTENTIONAL production of false or grossly exaggerated physical or psych sx motivated by external incentives 
Avoiding military duty
Avoiding work
Obtaining financial compensation
Evading criminal prosecution
Obtaining drugs
This is not considered a mental disorder

Onset is in response to environmental incentives
Often uncooperative with exam
Seen in pt with ASPD

Waddells sign for malingering:
*put your hand on type of their head, have them plant their feet and turn them back and forth

Question 21

Tx of Malingering

Answer 21

1) Eliminate external incentive which is the motivator
2) Appropriate dx eval and careful documentation
3) Confront pt in firm, confidential and empathetic manner