Somatoform & Factitious Disorders

Factitious Disorder Physical or psychological Sx that are intentionally feigned for the purpose of fulfilling an intrapsychic need to adopt a sick role. Presents history very dramatically with vague & inconsistent details When confronted with evidence of inconsistencies, will deny allegations and often avoid further evaluation These individuals have frequently had numerous surgeries or other invasive medical procedures.

Factitious Disorder l Primarily physical l Primarily psychological

Malingering

Somatoform Disorders l Presentation of physical symptoms that suggest a physical disorder –Symptoms not fully explained by: l The medical condition l Substance use l Another mental disorder l Must judge the onset, severity, and duration of symptoms for proper diagnosis

Somatoform Disorders l Somatization disorder l Conversion disorder l Hypochondriasis l Body dysmorphic disorder l Pain disorder l Two other residual categories

Somatization Disorder l History of many physical complaints beginning before 30. Very chronic course and result in tx being sought or significant role impairment. l During a episode, the following must occur –4 pain sx –2 GI sx –one sexual sx –and 1 psuedoneurological sx

Somatization continued l Not due to GMC or l When related to GMC, the resulting social or occupational impairment are ins excess of what would be expected from physical exam, history, or labs

Somatization D/O- Epidemiology l Rare in men; much more common in psychiatric patients l More among low SES groups and EMs l 20% of 1st degree female relatives of these pts. will have a somatization d/o. l Differentials

First Aid for Somatizers l Recent study found that a brief psychiatric consultation followed by a letter to the doctor greatly reduced cost and somaticizing tendencies. l Schedule brief appointments and Phx. Exams every 4 to 6 weeks; only at set times and NOT on demand; avoid lab tests, surgery and hospitalization unless absolutely necessary and avoid suggesting that the problems are all in his/her mind l Charges fell 25 to 33% as did subjective pain Smith, Rost & Kashner (1995). Archives of General Psychiatry, 52.

Case Example l 44 year-old African American pt. With reported history of recent TBI in which he was kicked in the back of the head and everything went black. l NP Testing: MMSE=13, poor memory and exec. functioning. Language intact l Presentation and follow-up

Conversion Disorder l Usually a single motor or neurological symptom with symbolic meaning that affects voluntary motor or sensory function. l Frequently primary (protects) or secondary gain (gratifies). l Sudden onset of symptoms (usually a temporal relationship)

Conversion D/O Etiology & Prevalence l Equal in men and women l More common in lower SES groups and in subcultures that consider these symptoms as being expectable l Often medical impossibility that confirms their conceptualization of CNS function

Conversion D/O Treatment l Important to rule out GMC such as Multiple Sclerosis and Lupus l Remove from situation, reinforce alternative coping strategies and occasionally hypnosis

Pain Disorder-Presentation l Symptoms are usually initiated by an acute stressor, erupt suddenly, intensify over the next several days or weeks and subside when the acute stressor is gone. l Patients frequently have secondary gain (“doctor shop”) and have symptoms that worsen under stress.

Pain D/O Epidemiology & Prevalence l Initially afflict women more, but sex differences fall out after major depression is eliminated. l More common in relative with pain problems and patients with physically demanding jobs.

Pain D/O Treatment l Acute management- giving insufficient narcotics leads to moderate and severe distress in 3/4 of the patients. Drs. fear addiction. Don’t give narcotics PRN!! l Chronic management- Cognitive behavioral therapy, pharmacotherapy and “team” tx.

Hypochondriac l Overwhelming, persistent preoccupation with physical sxs. based on unrealistically ominous interpretation of physical signs or sx l Ex. Felix Unger l Affects both sexes equally; begins l La belle indifference

Body Dysmorphic Disorder l Focus on obsession with perceived fault in physical appearance or imagined image l Greater in women (3:1) l Mood disorders usually come AFTER not before the sx of BDD l Treatment –Behavior therapy and serotonergic antidepressants (OCD variant?)