Somatic Symptoms and Related Disorders; Nonadherence to Medical Treatment

Question 1

Factitious Disorder etiology, RF, sxs

Answer 1

• imposed on self - feces in veins, bleed themselves, induce hypoglycemia, put blood in urine
• rare; intentionally f aking sxs in order to assume sick role or role of pt, even in absence of external gain
• MC falsified sxs: abd pain, jnt pain, chest pain, coagulopathy, D, hematuria, hypercort, hyperthyroid, hypoglyc, infxn, szs, skin wounds that dont heal, V, weakness
• Most frequent psychiatric factitious sxs: bereavement, depression, psychosis, suicidal ideation
• munchausen by proxy syndrome (most severe case): caregiver causes harm to child for child to be sick (child abuse)
• sxs: sxs physical but can mimic psychiatric illness, intentionally induced, goal is NOT to dupe doctor or for internal incentives, but to assume a “sick” role, no obvious extenral benefits (financial gain, avoiding work, or criminal prosecution)

Question 2

Factitious disorder dx and tx

Answer 2

• dx: medical records from prior eps, video monitor or 1:1 sitter, collateral contacts (info provided by family and friends)
  
  • DSM 5 criteria:
    
    • 1. falsifying physical or psych signs or sxs or induction of injury . or disease associated with identified deception
    • 2. presents themselves to tohers as ill, impaired, or injured
    • 3. deceptive behavior is evident in absence of obvious external rewards
    • 4. behavior not better explained by anotther mental disorder such as delusional disorder or psychotic disorder
• tx: consult psych, inform all members of team about dx and plan, assess suicide risk, monitor pt to prevent self-injurious behaviors, tx comorbid psych disorder, maintain awareness of countertransference (clinician’s feelings and thoughts about pt), psychotx
• prognosis: poor, infrequent recovery

Question 3

illness anxiety disorder (IAD) - hypochondriasis

Answer 3

• preoccupation with having or acquiring a specific illness, anxiety . about health status (excessive health-related behavior and avoidant behaviors, M = F
• onset: early adulthood, rarely after 50yo
• ddx: OCD
• DSM 5 criteria:
  
  • at least 6 mo
  • preoccupation with having or acquiring serious, undiagnosed illness depsite appropriate medical eval and reassurance
  • somatic sxs are mild or nonexistent at most
  • substantial anxiety about health and a low threshhold for becoming alarmed about one’s health
  • either excessive behaviors related to heatlh (eg repeatedly checking oneself for signs of illness) or maladaptive avoidance of situations or activities (eg exercise) that are thought to provoke health threats
  • not better explained by other mental disorders
• dx: clinical dx, negative physical exam and lab testing
• tx: regular follow ups with PCP, acknowledge health fears, evaluate and treat diagnosable medical diseases/illnesses, limit dx testing and referrals, provide reassurance, tx comorbid psych disorders, make fnal improvement goal of tx
  
  • psychotx (CBT), SSRIs/SNRIs

Question 4

Somatic Symptom disorder

Answer 4

• distressing somatic sxs (abnl thoughts, feelings, and/or behaviors), multiple somatic sxs (pain common), chronic courses with significant disability, F>M
• sxs: at least 1 somatic sx that is distressing or causing impairment (psych distress)
  
  • disproportionate and persistent thoughts about seriousness of sxs, persistently high anxiety . about sxs or general health, excessive devotion of time/energy to sxs or health concerns
  • although specific somatic sx may change, disorder is persistent (>6 mo)
• dx: clinical, screening, somatic sx scale, somatic sx disorder B criteria scale, somoatic sx experiences questionairre
• tx: regularly scheduled visits with one PCP, become familiar and learn their typical from new sxs, minimize redundant workup, referrals, etc., minimize polypharmacy, ask about psychosocial support and stressors, encourage graduated exercise program
  
  • TCA, SSRI/SNRI, CBT, hypnosis