Somatoform and Factitious Disorders Flashcards
Somatoform Disorders
Category of disorders that present with physical symptoms that have no organic cause.
Truly believe their symptoms are due to medical problems and are not consciously feigning them
Examples Somatoform Disorders
somatization, conversion, hypochondriasis, pain, body dysmorphic
Primary gain of somatoform disorders
expression of unacceptable feelings as physical symptoms in order to avoid facing them
Secondary gain of somatoform disorders
Use of symptoms to benefit patient ie increased attention from others, decreased responsibilities, avoidance of the law
Demographics somatoform disorders
with the exception of hypochondriasis, SDs are more common in women
50% patients have comorbid mental disorders esp. anxiety and MDD
Somatization Disorder description
patients present with multiple vague complaints involving many organ symptoms.
long history of visits to doctors.
Symptoms not explained by medical condition
DSM IV criteria for Somatization Disorder
At least 2 GI symptoms
At least 1 sexual or reproductive symptom
At least 1 neuro symptom
At least 4 pain symptoms
Onset before 30
Cannot be explained by general medical condition or substance
Epidemiology of Somatization Disorder
Women 5-20x more common low socioeconomic groups lifetime prevalence .1-.5% 50% have comorbid mental disorder 30% concordance in identical twins
Course of Somatization Disorder
Usually chronic and debilitating
Treatment of Somatization Disorder
frequent visits to PCP (won’t see a psych doc)
minimize secondary gain
meds should be avoided
relaxation therapy, hypnosis, individual and group psychotherapy
Conversion Disorder description
Present with at least one neuro symptom that cannot be explained
Onset ALWAYS preceded by psych stressor (but patient may not connect the two)
Patients often weirdly calm and unconcerned about their symptoms
Conversion Disorder Common symptoms
Shifting Paralysis blindness mutism paresthesias seizures globus hystericus (lump in throat)
DSM IV Conversion Disorder
- At least 1 neuro symptom
- psych factors ass. w/ initiation or exacerbation of symptom
- symptom not intentionally produced
- cannot be explained by med cond or sub. abuse
- causes sig distress or impairment in social or occupational functioning
- not accounted for by somatization disorder or other mental disorder
- not limited to pain or sexual symptoms
Conversion Disorder Epidemiology
- Common: 20-25% incidence in general medical settings
- 2-5x more common women
- onset at any age; more common adolescence or early adulthood
- increased low socioeconomic groups
- high incidence comorbid schizophrenia, MDD, anxiety
Conversion Disorder Differential Diagnosis
MUST rule out medical cause; 50% of patients with diagnosis eventually find medical reason
Conversion Disorder Course
symptoms resolve within 1 month
25% have future episodes esp. during stress
symptoms may resolve spontaneously after hypnosis or sodium amobarbital interview if the psych trigger can be uncovered
Conversion Disorder Treatment
Insight oriented psychotherapy, hypnosis, relaxation therapy
most patients recover spontaneously
Hypochondriasis Description
prolonged, exaggerated concern about health and possible illness
patients either fear having a disease or are convinced that one is present
misinterpret normal bodily symptoms as indicative of disease
DSM IV Hypochondriasis
- Patients fear that they have a serious medical condition based on misinterpretation of normal body symptoms
- fears despite appropriate medical eval
- fears present for at least SIX MONTHS
Hypochondriasis Epidemiology
Men = Women
Average onset 20-30 yo
80% comorbid MDD or anxiety
Hypochondriasis Differential Diagnosis
Must rule out underlying medical condition
Somatization disorder - hypochons are worried about disease, somats are worried about symptoms
Hypochondriasis Course
Episodic-symptoms wax and wane
Exacerbations under stress
50% improve significantly
Hypochondriasis Treatment
No cure
freq visits to ONE PCP who oversees care
Patients resistant to psychotherapy
Group or insight-oriented therapy can be helpful if patient is cooperative
Body Dysmorphic Disorder (BDD) Description
preoccupied with body parts they perceive as flawed or defective
flaws are minimal or imaginary but patients find them grotesque
extremely self conscious about appearance; go great lengths to try and correct w/ makeup, surgery, etc
BDD DSM IV
- preoccupation with an imagined defect in appearance or excessive concern about slight physical anomaly
- must cause sig distress in the patient’s life
BDD epidemiology
women more than men more common unmarried ppl average age onset 15-20 yo 90% have MDD 70% have anxiety 30% are psychotic
BDD Course/Prognosis
usually chronic; symptoms wax and wane in intensity
BDD treatment
surgical or derm procedures are routinely unsuccessful in pleasing patient
SSRIs reduce symptoms in 50%
Pain Disorder Description
prolonged, severe discomfort w/o adequate med explanation
pain often coexists w/ med condition but is not caused by it
patients often have history of multiple visits to doctors
can be acute (< 6 months) or chronic (> 6 months)
Pain DSM IV
- patient’s main complaint is of pain at one or more anatomic sites
- pain causes sig distress
- pain has to be related to psych factors
- pain is not due to med disorder
Pain Epidemiology
women 2x average age onset 30-50 inc. incidence in 1 deg relatives inc. incidence in blue collar workers patients have higher incid. of MDD, anxiety and sub. abuse
Pain Diff Diagnosis
rule out underlying med condition
rule out hypochondriasis and malingering
Pain Course
Abrupt onset and inc intensity for first few months; usu chronic and disabling course
Pain Disorder Treatment
Analgesics NOT HELPFUL > patients may develop dependence
SSRIs, transient nerve stimulation, biofeedback, hypnosis, psychotherapy may help
Factitious Disorder Description
patients intentionally produce medical or psychological symps in order to assume role of sick patient
primary gain is prominent feature of disorder
Factitious DSM IV
- Patients intentionally produce signs of physical or mental disorders
- they produce the symptoms to assume the role of the patient (primary gain)
- there are no external incentives (money)
- either predominantly psychiatric complaints or predominantly physical complaints
Commonly feigned symptoms factitious disorder
psychiatric - hallucinations, depression
medical- fever (by heating thermometer), abdominal pain, seizures, skin lesions, hematuria
Munchhausen Syndrome
- another name for factitious disorder with predominantly physical complaints
- patients may take insulin, consume blood thinners, etc
- often demand specific meds
- very skilled at feigning symps that necessitate hospitalization
Munchhausen syndrome by proxy
intentionally producing symptoms in someone else who is under one’s care (usually one’s children) in order to assume the sick role by proxy
Epidemiology of Factitious Disorder
- > 5% hosp. patients
- inc. incid in males
- higher incidence in hospital and health care workers
- associated with higher intelligence, poor sense of identity, poor sexual adjustment
- many patients history of child abuse or neglect (inpatient hospitalization = safe, comforting environment)
Treatment factitious
important to avoid unnecessary procedures and maintain close liaison with patient’s PCP
patients confronted in the hospital usually leave
Malingering definition
feigning physical or psychological symptoms in order to achieve personal gain
Common motivations for malingering
avoiding the police, receiving room and board, obtaining narcotics, receiving monetary compensation
Presentation of Malingering Patient
- usually have multiple vague symptoms that do not conform to a known medical condition
- usually long med history w/ many hospital stays
- generally uncooperative and refuse to accept a good prognosis even after extensive eval
- symptoms improve once desired objective is obtained
Epidemiology of Malingering Patient
common in hospitalized patients; more common in men
Distinguishing feature of somatoform disorders versus malingering or factitious
patients BELIEVE they are ill
Distinguishing feature of factitious versus somatoform or malingering
patients PRETEND they are ill with no obvious external reward
Distinguishing malingering (most common) versus somatoform or factitious
patients PRETEND they are ill with obvious EXTERNAL INCENTIVE
