Somatoform & Factitious Disorders

1. Somatoform & Factitious Disorders

2. 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.

3. Factitious Disorder • Primarily physical • Primarily psychological

4. Malingering

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

6. Somatoform Disorders • Somatization disorder • Conversion disorder • Hypochondriasis • Body dysmorphic disorder • Pain disorder • Two other residual categories

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

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

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

10. First Aid for Somatizers • Recent study found that a brief psychiatric consultation followed by a letter to the doctor greatly reduced cost and somaticizing tendencies. • 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 • Charges fell 25 to 33% as did subjective pain Smith, Rost & Kashner (1995). Archives of General Psychiatry, 52.

11. Case Example • 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. • NP Testing: MMSE=13, poor memory and exec. functioning. Language intact • Presentation and follow-up

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

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

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

15. Pain Disorder-Presentation • 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. • Patients frequently have secondary gain (“doctor shop”) and have symptoms that worsen under stress.

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

17. Pain D/O Treatment • 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!! • Chronic management- Cognitive behavioral therapy, pharmacotherapy and “team” tx.

18. Hypochondriac • Overwhelming, persistent preoccupation with physical sxs. based on unrealistically ominous interpretation of physical signs or sx • Ex. Felix Unger • Affects both sexes equally; begins 20-30 • La belle indifference

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