Somatoform & Factitious Disorders

1. Somatoform & Factitious Disorders (Thanks to: Drew Bradlyn, Ph.D.)

2. Somatoform Disorders • Key Feature: • Types • Somatization Disorder • Conversion Disorder • Hypochondriasis • Somatoform Pain Disorder • Body Dysmorphic Syndrome • Undifferentiated Somatoform Disorder

3. Quick but irrelevant • Body Dysmorphic Disorder • Pain Disorder

4. Somatization Disorder:Diagnostic Features • Key feature: Multiple, unexplained symptoms • Criteria • 4 pain • 2 GI • 1 sexual/reproductive • 1 pseudoneurological • If within a medical condition, XS sxs • Lab abnormalities absent • Not intentionally feigned or produced

5. Somatization Disorder: Associated Features • Colorful, exaggerated terms • Inconsistent historians • Depressed mood and anxiety symptoms • Chronic, rarely remits completely • Lifetime prevalence: 0.2% - 2% F < 0.2% among men

6. Hypochondriasis:Diagnostic Features • Key feature: fear/belief--disease • Criteria • Unwarranted fear or idea persists despite reassurance • Clinically significant distress • Not restricted to appearance • Not of delusional intensity

7. Hypochondriasis:Associated Features • Medical history often presented in great detail • Doctor-shopping common • Patient may believe s/he is not receiving proper care • Patient may receive cursory PE; med condition may be missed • Negative lab/physical exam results • M = F • Primary care prevalence: 4 - 9% • May become a complete invalid

8. Conversion Disorder:Diagnostic Features • Key Feature: • Criteria • Symptoms are preceded by stressors • Symptoms are not intentionally feigned or produced • No neuro, medical, substance abuse or cultural explanation • Must cause marked distress

9. Conversion Disorder:Associated Features • In 10 - 50% ->physical disease • F > M (varies from 2:1 to 10:1) • Symptoms do not conform… Prevalence ranges from 11/100,000 to 300/100,000 • Outpatient mental health: 1 - 3% • “la belle indifference” • Histrionic • Figure of identity

10. More on Somatoform • Hypochondriasis is most common (M = F) • Somatization disorder lifetime risk for F <3% • Conversion and somatoform pain d/o F > M, but found in <1% of population • Higher incidence in medical settings (?50%) • 10% of med-surg patients have no physical evidence of disease • Costs of evaluating and treating = $30 billion in 1991

11. Gains of illness Social isolation Amplification Symptoms used as communication Physiologic concomitants of psych d/o Cultural attitudes Religious factors Stigmatization of psych illness Economic issues Symptomatic treatment Ford (1992) Factors that Facilitate Somatization

12. Differential

13. Differential • Things that affect: • Concrete findings • Perception of Illness • Presentation of Illness

14. “Concrete” • Diseases that don’t follow the rules

15. Perception • Psych diseases: • Depression • Anxiety • Psychosis • Other, weirder stuff

16. Presentation • Malingering • Factitious Disorder • More normal things

17. Factitious Disorder • Key Feature: Sx’s Intentionally produced to assume sick role • Types • Factitious Disorder • Factitious Disorder by Proxy

18. Factitious Disorder:Associated Features • M > F • Hospital/healthcare workers • External incentives absent • Distinguished from somatoform… Distinguished from malingering…

19. Review Question • 32 YO unmarried woman is told by her doctor that his is leaving on a vacation. 1 week later, the doc gets an emergency call, finds the patient reporting herself to be in labor: with HIS child. On examination, the patient appears bloated and in distress, but not actually pregnant. • What’s going on!

20. Review Question • 42 YO man presents to a PMD saying that he believes he has Lyme’s disease. His main sx is chronic and persistent headaches. He explains that 2 courses of oral amoxicillin and ceftriaxone have not helped, and he is asking for oral antibiotics. The patient is persistent: saying last doctor didn’t know what he was doing, and that his wife is getting very frustrated with him. History reveals no risk factors, exam is unremarkable, Lyme titer is negative. What is the most likely diagnosis? What’s going on?

21. Review Question • A neurologist consults you on a patient: he notes that he has diagnosed MS in the this 35 YO woman, but is skeptical whether she really has it. He says that her major symptom is an “odd walk” which doesn’t conform to any gait deformity he has seen. On interview, patient is pleasant. She is aware of the oddness of her walk, and the growing doubt among her doctors. She cannot explain her gait, only describing a sense of weakness. How would you approach this patient What would you ask to help diagnose the case.