Somatiform Disorders

Question 1

List examples of somatoform disorders

Answer 1

1. Somatization disorder (Somatic symptom disorder now)
2. Conversion disorder
3. Hypochondriasis (DSM IV only)
4. Body dysmorphic disorder (BDD)
5. Pain disorder (DSM IV only)
6. Factitious disorder
7. Malingering

Question 2

General characteristics of somatoform disorders?

Answer 2

1. Both unconscious and social factors involved that might result in primary or secondary gain: primary is INTERNAL/psychic motivation, and secondary are EXTERNAL motivations, like needing housing, disability, drugs, need to be cared for
2. Seen more in WOMEN, except hypochondriasis
3. Usually starts in EARLY ADULTHOOD, and worsens with STRESS
4. half with co-morbid mental illness: anxiety, depression
5. Causes impairment in social and/or occupational function

Question 3

Etiology of somatoform disorders?

Answer 3

1. Somatization disorder, hypochondriasis, pain disorder tend to run in families (look at monozygotic and dizygotic twins with increased incidence)
2. Hypo and pain disorders with increased incidence with FH of mood disorder or OCD
3. Somati disorder with increased incidence with FH of antisocial personality disorder or alcoholism
4. Maybe serotonin-related gene pathways involved (their hypofunction)

Question 4

For somatization disorder, what things must be present?

Answer 4

1. > or = 4 pain issues (2 GI, 1 sexual, 1 neurological symptom: they can’t be adequately explained by medical issues after history, examination, labs, tests)
2. Onset BEFORE age 30
3. Symptoms tend to be chronic with RARE complete remission
4. Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Question 5

Conversion disorder

Answer 5

1. Suddenly, dramatically lose one or more voluntary motor and/or sensory functions (maybe neurologic etiology?)
2. Preceded by psychological stress or conflict (presenting symptom tends to have symbolic relationship with stressor and serves to decrease anxiety associated with it); e.g. shooting someone in self defense = right arm paralysis
3. La belle indifference (patient seems uncaring/unconcerned about their symptoms)
4. Usually self-limited with remission in <1 month
5. More common in psychiatrically unsophisticated and those with depression or histrionic personality traits
6. Unconscious, no secondary gain, patient aware of loss and symptoms generation!!

Question 6

In conversion disorder, what do you see in terms of symptoms?

Answer 6

Motor: shifting paralysis, pseudoseizures, globus hystericus
Sensory: paresthesias, anesthesias, vision/hearing problems;
pseudoneurologic symptoms tend not to match the way nerves fire:
1. wrong dermatomes for sensory loss
2. blindness with optokinetic effects
3. during seizure can sneeze or react to pain
4. pain radiates DOWN instead of up
5. Seizure head movements are VERTICAL, not horizontal

Question 7

Hypochondriasis:

Answer 7

1. Fear or idea of having serious mental illness based on misinterpretation of bodily symptoms
2. Persists despite negative findings and reassurance after med work-ups (could cause DOCTOR SHOPPING)
3. Symptoms must last for > or = 6 mos
4. Could have similar etiology to OCD, generalized anxiety disorder, and impulse control disorders (SSRI’s might help)
5. Renamed Illness anxiety disorder (high health anxiety WITHOUT somatic symptoms)
6. Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried!!

Question 8

BDD:

Answer 8

1. Preoccupied with IMAGINED problem or insignificant abnormality in appearance (usually face or head, like breasts not symmetrical, muscles too small, etc)
2. Cannot be accounted for by eating disorder (anorexics are body dysmorphic thinking they are overweight)
3. Plastic surgery or med interventions rarely relieve symptoms but are commonplace
4. Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Question 9

Pain Disorder

Answer 9

1. Protacted pain that is severe enough to cause patient to seek med attention
2. Can’t be explained by PHYSICAL causes
3. Acute < 6mos, chronic > or = 6 mos
4. Typical age of onset during THIRD or FOURTH decade of life
5. Can be disabling and cause dependence on pain meds
6. Unconscious, no secondary gain, patient unaware of behaviors and symptom generation, very concerned and worried

Question 10

For the first five somatoform disorders discussed, what is the DD?

Answer 10

1. Rule out true unidentified organic illness!!
2. Depression and anxiety can be great pretenders!!
3. Factitious disorders and malingering, they are CONSCIOUSLY driven, feigned, and created whereas these others are UNCONSCIOUS and without clear secondary gain

Question 11

How do you manage the first five disorders?

Answer 11

1. Strong doctor-patient relationship (short appointments, reassurance, empathy!!)
2. ID and help decrease SOCIAL STRESSORS and MOTIVATIONS for primary gain
3. Psychopharm for co-morbid depression and/or anxiety (SSRI’s good for hypochondriasis, BDD, pain disorder)
4. Drug-assisted interviewing with Na amobarbital or hypnosis might be of help with conversion disorder (allow face saving opportunities, refer for non-invasive physical physical or occupational therapy)
5. Psychotherapy, hypnosis, and interpersonal and CBT might be helpful
6. Symptoms often recur when stress mounts!!

Question 12

Factitious disorder

Answer 12

1. originally Munchausen syndrome (by Proxy if you create medical problems in others)
2. Unknown whether or not this is a true somatic disorder
3. CONSCIOUS feigning or production of physical or mental illness in order to receive attention from med personnel (to assume the “sick” rule, 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?
4. Get angry and leave quickly when confronted
5. More common in people who WORK IN MED FIELD
6. Tends to have NEGATIVE impact on work, school, and/or social functioning

Question 13

For factitious disorder, what are commonly feigned or produced signs and symptoms?

Answer 13

1. Abdo pain (“grid abdomen” could signify previous unnecessary surgical procedures; can happen with somatic pain disorder also)
2. Fever (heating a thermometer)
3. Hematuria (blood from needle stick)
4. Seizures (take excess caffeine, theophylline)
5. Skin lesions (easily reached areas by chemical dermatitis)
6. Tachy (drug-incuded)
7. Hypoglycemia (insulin injection: look for increased insulin but LOW C-peptide)
8. Fever (inject feces)
9. DVT (use ligature)

Question 14

Factitious Order by proxy:

Answer 14

1. Most commonly, a parent feigns or induces illness in a child to gain attention for him/herself
2. Considered a form of child abuse and must be reported
3. Parent might have history of CHILDHOOD ABUSE/neglect or serious childhood illness during which he/she felt cared for and protected by med personnel
4. May like being the expert in his/her child’s care

Question 15

Malingering:

Answer 15

1. NOT a psychiatric illness (could be a crime)
2. Conscious simulation or exaggeration of physical or mental illness to achieve some sort of secondary gain (disability, drugs in ER, leave of absence/AWOL)
3. Symptoms improve as soon as secondary gain is obtained
4. Seen more frequently in the INCARCERATED and people involved in LAWSUITS