Lecture 9-Somatoform disorders

Question 1

Physical Symptom (not explained by medical condition or substance abuse)–with concious production of symotoms and unconcious motivation =

Answer 1

facticious disorder

Question 2

Physical Symptom (not explained by medical condition or substance abuse)–with concious production of symotoms and concious motivation =

Answer 2

malingering

Question 3

Physical Symptom (not explained by medical condition or substance abuse)–with unconcious production of symotoms = ______ disorder or _____ disorder

Answer 3

depressive or anxiety; Somatization disorder (conversion disorder)

Question 4

In somatization disorders what is primary and secondary gain?

Answer 4

Primary gain: internal/psychic motivations (unconscious)

Secondary gain: external (purposeful) motivations (need housing, disability, drugs, need to be cared for)

Question 5

Somatization disorder, hypochondriasis, and pain disorder tend to run in ____

Answer 5

families

Question 6

Somatization Disorder =

≥4 pain issues:
__ gastrointestinal,
__ sexual,
__ neurological symptom

None can adequately be explained by medical causes after history, examination, labs, tests

Answer 6

2; 1; 1

Question 7

Somatization disorder is ______, _____ secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Answer 7

unconscious; no

Question 8

What is conversion disorder? What is it triggered by? Examples?

Answer 8

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

Examples: Seeing something violent = blindness, Shooting someone in self defense = right arm paralysis, Group Conversions can occur too

The term “conversion” has its origins in Freud’s doctrine that anxiety is “converted” into physical symptoms.

Question 9

Conversion disorder is _____, ____ secondary gain, patient aware of loss and symptom generation.

Patient is _____ about their remarkable symptoms.

Answer 9

unconscious; no; unconcered

Question 10

What is hypochondriasis? Does it persist after ruling out disease? How long must symptoms exist for?

Answer 10

Fear or idea of having a serious medical illness based on misinterpretation of normal bodily symptoms- now thought to be part of generalized anxiety disorder (GAD) spectrum…

Persists despite negative findings and reassurance after medical work ups

Symptoms must persist for ≥6 months

Question 11

Hypochondriasis is _____, ____ secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Answer 11

unconscious; no

Question 12

Body Dysmorphic Disorder?

Answer 12

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

Examples:

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

Question 13

Body dysmorphic disorfer is _____, _____ secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Answer 13

unconscious; no

Question 14

Pain disorder?

Answer 14

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

Cannot be explained by physical causes

Acute (<6 months) or chronic (≥6 months)

Question 15

Pain disorder is _____, ____ secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Answer 15

Unconscious; no

Question 16

Factitious disorders and malingering are ____ driven, feigned, created in order to secondarily _____ something (sick role, housing, disability, drugs)

Answer 16

consciously; gain

Question 17

How do we manage patients with unconcous production of symptoms? What medications can we give?

Answer 17

Establish a strong doctor-patient relationship – regular short appointments, constant reassurance, empathy

Best treatment is lengthy but to obtain records from everywhere, talk to as many providers and family members as possible, frequent focused medical visits(Not psych ones), avoid over medicalizing or procedurizing the patient, have one managing PCP that must clear all procedures and referrals to specialists… simplify everything;

Psychopharmacology for co-morbid depression and/or anxiety - SSRIs** have been shown to be particularly useful for hypochondriasis, body dysmorphic disorder, and pain disorder

Question 18

Drug-assisted interviewing with sodium amobarbital (truth serum) or hypnosis may be of help with _____ disorder

Answer 18

conversion

Question 19

Facticious disorder? By proxy?

Answer 19

Conscious feigning or production of physical or mental illness in order to receive attention from medical personnel – to assume the “sick” role, a primary gain to feel safe and cared for, possible secondary gain to feel proud, an expert, able to figure things out that doctors cannot

Get angry and leave quickly when confronted

More common in people who work in the medical field

‘by Proxy’ if you create medical problems in others (like children by parents)

Question 20

Malingering?

Answer 20

Conscious simulation or exaggeration of physical or mental illness to achieve some sort of secondary gain: Disability, Drugs in the ER, Leave of absence/ AWOL

Symptoms improve as soon as the secondary gain is obtained

Question 21

An elderly man presents with blindness after witnessing his house burn down. He is very calm in the Emergency Department and does not appear concerned about his condition. What is the most likely diagnosis?

1 Bilateral opthalmic artery strokes

2 Cortical bruise to occiptal lobe

3 Factitious disorder

4 Conversion disorder

Answer 21

4 Conversion disorder

Question 22

In general, what is the best treatment for somatic-type disorders?

1 Order every possible invasive test to rule out a bona fide medical issue

2 Refer to specialists to obtain the most accurate assessment

3 Simplify the # of providers, medications and procedures

4 Refer to psychiatry for intensive management

Answer 22

3 Simplify the # of providers, medications and procedures

Question 23

A 49 year old man presents with right arm paralysis after he witnessed a similar accident at his work site (4 months ago) where a colleague injured his brachial plexus operating a machine. He is very concerned, grimacing in agony, refusing to move the arm despite there being no clear trauma. He asks for morphine and a doctor’s note to skip work this week. What is his diagnosis?

1 Factitious disorder

2 Somatic Symptom disorder (Somatization)

3 Malingering

4 Conversion disorder

Answer 23

3 Malingering

NOTE:

Malingering because of the secondary gain (morphine & skip work).

Without the secondary gain = a conversion disorder.