Somatoform and Factitious Disorders

Question 1

Somatoform Disorders

Answer 1

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

Question 2

Examples Somatoform Disorders

Answer 2

somatization, conversion, hypochondriasis, pain, body dysmorphic

Question 3

Primary gain of somatoform disorders

Answer 3

expression of unacceptable feelings as physical symptoms in order to avoid facing them

Question 4

Secondary gain of somatoform disorders

Answer 4

Use of symptoms to benefit patient ie increased attention from others, decreased responsibilities, avoidance of the law

Question 5

Demographics somatoform disorders

Answer 5

with the exception of hypochondriasis, SDs are more common in women

50% patients have comorbid mental disorders esp. anxiety and MDD

Question 6

Somatization Disorder description

Answer 6

patients present with multiple vague complaints involving many organ symptoms.

long history of visits to doctors.

Symptoms not explained by medical condition

Question 7

DSM IV criteria for Somatization Disorder

Answer 7

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

Question 8

Epidemiology of Somatization Disorder

Answer 8

Women 5-20x more common
low socioeconomic groups
lifetime prevalence .1-.5%
50% have comorbid mental disorder
30% concordance in identical twins

Question 9

Course of Somatization Disorder

Answer 9

Usually chronic and debilitating

Question 10

Treatment of Somatization Disorder

Answer 10

frequent visits to PCP (won’t see a psych doc)
minimize secondary gain
meds should be avoided
relaxation therapy, hypnosis, individual and group psychotherapy

Question 11

Conversion Disorder description

Answer 11

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

Question 12

Conversion Disorder Common symptoms

Answer 12

Shifting Paralysis
blindness
mutism
paresthesias
seizures
globus hystericus (lump in throat)

Question 13

DSM IV Conversion Disorder

Answer 13

• 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

Question 14

Conversion Disorder Epidemiology

Answer 14

• 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

Question 15

Conversion Disorder Differential Diagnosis

Answer 15

MUST rule out medical cause; 50% of patients with diagnosis eventually find medical reason

Question 16

Conversion Disorder Course

Answer 16

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

Question 17

Conversion Disorder Treatment

Answer 17

Insight oriented psychotherapy, hypnosis, relaxation therapy

most patients recover spontaneously

Question 18

Hypochondriasis Description

Answer 18

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

Question 19

DSM IV Hypochondriasis

Answer 19

• 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

Question 20

Hypochondriasis Epidemiology

Answer 20

Men = Women
Average onset 20-30 yo
80% comorbid MDD or anxiety

Question 21

Hypochondriasis Differential Diagnosis

Answer 21

Must rule out underlying medical condition

Somatization disorder - hypochons are worried about disease, somats are worried about symptoms

Question 22

Hypochondriasis Course

Answer 22

Episodic-symptoms wax and wane
Exacerbations under stress
50% improve significantly

Question 23

Hypochondriasis Treatment

Answer 23

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

Question 24

Body Dysmorphic Disorder (BDD) Description

Answer 24

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

Question 25

BDD DSM IV

Answer 25

- preoccupation with an imagined defect in appearance or excessive concern about slight physical anomaly - must cause sig distress in the patient's life

Question 26

BDD epidemiology

Answer 26

``` women more than men more common unmarried ppl average age onset 15-20 yo 90% have MDD 70% have anxiety 30% are psychotic ```

Question 27

BDD Course/Prognosis

Answer 27

usually chronic; symptoms wax and wane in intensity

Question 28

BDD treatment

Answer 28

surgical or derm procedures are routinely unsuccessful in pleasing patient SSRIs reduce symptoms in 50%

Question 29

Pain Disorder Description

Answer 29

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)

Question 30

Pain DSM IV

Answer 30

- 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

Question 31

Pain Epidemiology

Answer 31

``` 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 ```

Question 32

Pain Diff Diagnosis

Answer 32

rule out underlying med condition | rule out hypochondriasis and malingering

Question 33

Pain Course

Answer 33

Abrupt onset and inc intensity for first few months; usu chronic and disabling course

Question 34

Pain Disorder Treatment

Answer 34

Analgesics NOT HELPFUL > patients may develop dependence SSRIs, transient nerve stimulation, biofeedback, hypnosis, psychotherapy may help

Question 35

Factitious Disorder Description

Answer 35

patients intentionally produce medical or psychological symps in order to assume role of sick patient primary gain is prominent feature of disorder

Question 36

Factitious DSM IV

Answer 36

- 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

Question 37

Commonly feigned symptoms factitious disorder

Answer 37

psychiatric - hallucinations, depression | medical- fever (by heating thermometer), abdominal pain, seizures, skin lesions, hematuria

Question 38

Munchhausen Syndrome

Answer 38

- 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

Question 39

Munchhausen syndrome by proxy

Answer 39

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

Question 40

Epidemiology of Factitious Disorder

Answer 40

- >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)

Question 41

Treatment factitious

Answer 41

important to avoid unnecessary procedures and maintain close liaison with patient's PCP patients confronted in the hospital usually leave

Question 42

Malingering definition

Answer 42

feigning physical or psychological symptoms in order to achieve personal gain

Question 43

Common motivations for malingering

Answer 43

avoiding the police, receiving room and board, obtaining narcotics, receiving monetary compensation

Question 44

Presentation of Malingering Patient

Answer 44

- 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

Question 45

Epidemiology of Malingering Patient

Answer 45

common in hospitalized patients; more common in men

Question 46

Distinguishing feature of somatoform disorders versus malingering or factitious

Answer 46

patients BELIEVE they are ill

Question 47

Distinguishing feature of factitious versus somatoform or malingering

Answer 47

patients PRETEND they are ill with no obvious external reward

Question 48

Distinguishing malingering (most common) versus somatoform or factitious

Answer 48

patients PRETEND they are ill with obvious EXTERNAL INCENTIVE