ICL 9.3: Somatic Symptoms & Related Disorders, factitious Disorders, Malingering

Question 1

what are somatic symptom disorders?

Answer 1

these are formerly categorized as Somatoform Disorders but the common thing between them all is distressing somatic symptoms

common feature = prominence of somatic symptoms associated with significant distress and impairment

patients have maladaptive thoughts, feelings, and behaviors in response to the somatic symptoms

there’s a lot of medical comorbidity with these disorders and thus seen primarily in medical settings, not a psychiatric clinic

Question 2

how do you treat somatic symptom disorders?

Answer 2

they’re difficult to treat because their presence doesn’t require the absence of physical disease

prominent focus on physical symptoms

symptoms are not consciously controlled!!!**

Question 3

what are examples of normal somatic symptoms?

Answer 3

ex. broken heart after a breakup
ex. headache or stomachache before a test

these are somatic symptoms in response to a psychological issue

the difference between a somatic symptom disorder and someone who has a stress headache is that it’s not controlling your life and you’re not having maladaptive responses

Question 4

which diseases can mimic somatic symptom disorders?

Answer 4

1 Multiple Sclerosis

2. CNS Syphilis
3. Brain tumor
4. SLE
5. Myasthenia Gravis

you also have to rule out psychiatric disease like depression and anxiety disorders which are under recognized with patients who come in with somatic complaints like not eating or sleeping

Question 5

what are the contributing factors to somatic symptom disorders?

Answer 5

1. genetic vulnerability like increased sensitivity to pain
2. early experiences like prior traumas or attention from being ill
3. cultural norms, with respect to psychological vs. somatic symptoms; it may be okay to have a headache vs. having anxiety

Question 6

how does the somatic component effect depressive and anxiety disorders?

Answer 6

it complicates things by:
1. increasing severity

2. increasing functional impairment
3. refractoriness to treatment

Question 7

what is the definition of disease?

Answer 7

pathophysiological process and documentable lesions

an objective measure

Question 8

what is the definition of illness?

Answer 8

response of an individual and his/her family to symptoms

more subjective

Question 9

what is the definition of illness behavior?

Answer 9

attention patients give to and how they interpret their bodily symptoms, and what action they take about their symptoms

e.g., seek medical help, do they take medications as prescribed

Question 10

how can there be mismatches between disease and illness perception?

Answer 10

Patients with a disease such as HTN may not perceive themselves as ill and thus may not cooperate with their treatment especially if the medication is causing side effects whereas the HTP itself doesn’t

vs. a patients with a somatic symptom d/o may view selves as quite ill despite lack of objective evidence of having a disease

however, somatizing patients can have real diseases, in which case their subjective sense of illness is out of proportion to their disease

Question 11

what is abnormal illness behavior?

Answer 11

identification of an inappropriate or maladaptive way of perceiving, evaluating or acting with respect to one’s health status which persists despite recommendations from a health care professional as to nature of disease and appropriate treatment recommendations

abnormal illness behavior can be illness confirming or illness denying and can be focused on psychological or somatic symptoms –> so MDs are in the position where they have to determine what’s “normal” and “abnormal” by taking into account cultural norms

however, at the same time MDs may be demonstrating “abnormal treatment behaviors

Question 12

what are the 4 somatic symptom and related disorders?

Answer 12

1. somatic symptom disorder
2. illness anxiety disorder
3. conversion disorder
4. psychological factors affecting other medical conditions

Question 13

what is somatic symptom disorder?

Answer 13

multiple or just one severe symptom, e.g., pain that is distressing or results in significant disruption in daily life –> with severe SSD health concerns may become central feature of patients life to exclusion of other life events, dominating identity and interpersonal relationships

the patient’s distress is focused on somatic sx and their significance

can be specific (localized pain) or vague (fatigue)

can be normal bodily sensations that would not indicate disease/concern to most people but to this person it’s a major concern

so there are disproportionate and persistent thoughts and/or anxiety about seriousness of sx which result in repeated appraisal for seriousness since they are viewed as threatening, harmful or troublesome –> patients often think the worst of their sx, even with evidence to the contrary!!

the symptoms may or may not be associated with a medical condition

Those previously diagnosed with Somatization Disorder usually meet criteria for SSD

Question 14

are the symptoms people experience in somatic symptom disorder real?

Answer 14

YES

suffering is genuine irrespective of medically explainable cause of symptoms

Question 15

is the diagnosis of somatic symptom disorder and medical condition mutually exclusive?

Answer 15

no

diagnosis of SSD and medical condition are NOT mutually exclusive

the symptoms may or may not be associated with a medical condition

for example, someone who has an uncomplicated MI. even though the MI should not result in any disability, the patient may become severely disabled because they’re scared to go on a walk in fear that they’ll have another MI

Question 16

what is the DSM4 criteria for somatization disorder?

Answer 16

chronic syndrome of multiple somatic symptoms that cannot be explained medically

they seek medical attention frequently, frequent doctor shopping, have a lot of interpersonal problems because they spend so much time on their somatic symptoms

this is now categorized under somatic symptom disorder –> up to 75% of patients previously diagnosed with hypochondriasis now diagnosed with SSD (other 25% have illness anxiety disorder; would be Illness anxiety disorder if they do NOT have somatic sx)

hypochondriasis eliminated since perceived as pejorative dx

Question 17

what are the clinical features of somatization disorder?

Answer 17

involves multiple organ systems

must have:
- 4 pain symptoms: headaches, stomach aches, back pain

• 2 GI symptoms: NVD
• 1 sexual symptom: heavy menstration, pain with intercourse
• 1 pseudoneurological symptom: nonepileptic seizures, dizzy

Question 18

what is the DSM4 criteria for hypochondriasis?

Answer 18

1. excess concern about one’s health and disease despite the lack of any physical evidence to support such concerns

so people had a symptom and then got worried they have a disease associated with it like if they have stomach pain they think they have stomach cancer

people with somatic symptom disorder on the other hand just have a lot of symptoms

2. unrealistic interpretation of physical symptoms and sensations leading to fear one has serious disease
3. fear must persist for at least 6 months
4. exacerbations and remissions
   30-50% (often tied to levels of anxiety)

eventually have significant improvement

Question 19

how does somatic symptom disorder happen?

Answer 19

there’s a trigger that’s a perceived threat like preparing for an exam or having to get a report done for your boss which leads to apprehension

with the apprehension there develops an increased focus on the body and a preoccupation with perceived alteration/abnormality of bodily sensations/state

then there’s Interpretation of these bodily sensations and/or signs as indicating severe
illness

then the idea of the perceived illness becomes a perceived threat in and of itself so you keep going around and around in the loop

what you can do then is try to cut these off at certain points in the loop in therapy so you can help patients not have somatic symptoms

Question 20

how often do patients with somatic symptom disorder seek medical care?

Answer 20

pretty darn high

they’re looking for reassurance about symptoms but it does little to allay concerns

they often appear unresponsive to medical interventions

they may believe medical interventions are inadequate or feel that their symptoms aren’t being taken seriously

Question 21

what’s are the problems caused by somatic symptom disorder patients constantly seeking medical attention?

Answer 21

1. some very sensitive to medication side effects; if you have multiple doctors giving you lots of different medications

also running tests on them like CTs with contrast, this will be really hard on your kidneys

2. referral to mental health specialist often looked on with surprise or skepticism
3. associated with depression due to symptoms and thus suicide risk

Question 22

what are some of the prognostic factors of SSD?

Answer 22

comorbid anxiety and depression is common

often lower education level achieved

lower SES, unemployment

stressful life events

H/O sexual abuse or other childhood adversity

concurrent chronic physical illness or psychiatric disorders

reinforcing social factors – illness benefits

sensitization to pain

Question 23

how do we manage somatic symptom disorder patients?

Answer 23

1. make a brief physical examination; focusing on the organ system from which the patient has (new) complaints
2. look for signs of disease instead of symptoms
3. avoid tests and procedures unless indicated
4. reduce unnecessary drugs; do not use on-demand prescriptions and avoid habit-forming medication
5. treat any coexisting psychiatric disorders or consult psychiatrist;aAgree on a course with fixed, scheduled appointments with 2 to 6 week intervals
6. avoid giving patient sick leave
7. make the diagnosis of somatic symptom disorder

acknowledge the reality of the patient’s symptoms, let them know you don’t think they’re faking it but be direct and honest with the patient

accept the patient as being chronically ill

view new symptoms as emotional communication

single physician responsible for managing care so you know all the medications being used and what tests have been done

Question 24

what is illness anxiety disorder?

Answer 24

1. preoccupation with having or developing a serious medical illness
2. somatic symptoms are NOT present (or are mild); this is what differentiates it from SSD, it’s more focused on the anxiety
3. concern may develop from physical sensation but more likely from anxiety about the meaning of the possible diagnosis
4. if a medical condition is present it’s the anxiety/preoccupation that is out of proportion to the severity of the condition
5. illness is considered a core feature of their identity and a common response to stressful events
6. easily alarmed about illness; even just reading health related story or hearing about someone else’s illness gives them anxiety
7. involves frequent self-examination/checking behaviors (e.g., looking at throat in mirror)

often have extensive history of medical care; but no greater utilization of mental health care than general population, hmmmm interesting

concerns/anxieties do NOT respond to reassurance, negative tests; health professional reassurance may even heighten fears

25% of patients with hypochondriasis now diagnosed with Illness Anxiety disorder; the other 75% are diagnosed with somatic symptom disorder

Question 25

how does illness anxiety disorder effect relationships?

Answer 25

excessive worry can cause strain on relationships with family, friends, and health care professionals

Question 26

what is the course of illness anxiety disorder?

Answer 26

1. generally chronic, relapsing but may be transient
2. starts early or middle adulthood

rare in children

Question 27

what are the risk factors for developing illness anxiety disorder?

Answer 27

1. significant stressor – physical or emotional
2. childhood abuse
3. serious childhood illness

Question 28

what is conversion disorder?

Answer 28

a loss or change in voluntary motor or sensory function that cannot be explained by any known medical diagnosis –> psychological factors associated with symptoms because the initiation or exacerbation of the sx are preceded by conflicts or other stressors

1. one or more sx of altered voluntary motor or sensory function that can’t be explained by a medical disorder
2. distribution of disturbance inconsistent with known anatomical distribution
3. clinical findings provide evidence that sx are not compatible with recognized medical or neurological conditions
4. internal inconsistency at exam (physical signs elicited with one exam are no longer present if tested different way)

diagnosis should not be made just because test results normal or symptoms are unusual!

Question 29

what is often associated with the onset of conversion disorder?

Answer 29

onset may be associated with physical or psychological stress or trauma that is often temporally related to symptom onset

however, diagnosis should not be withheld if no associated stressor is uncovered

for example, a women was so proud of building up her own business but the business and house and car were in her husband’s name and they weren’t getting along; she had a bad argument and decided to leave him and he threatened that everything was in her name and as she was walking to her car she became paralyzed from her waist down

relevant psychological factors may not be demonstrable at time of diagnosis

Question 30

what are some of the motor symptoms that can be seen with conversion disorder?

Answer 30

1. weakness or paralysis
2. abnormal movements – tremor, dystonic movements
3. abnormal limb posturing

Question 31

what are some of the sensory symptoms that can be seen with conversion disorder?

Answer 31

altered, reduced or absent skin sensation, vision or hearing

Question 32

what are some of the pseudo symptoms that can be seen with conversion disorder?

Answer 32

Psychogenic Non-Epileptic Seizure (PNES)

these are abnormal generalized limb shaking with apparent impaired, or loss of, consciousness

up to 20% with intractable seizures found to have PNES, not epilepsy

this is much more common females than males

Question 33

what are the risk factors for developing Psychogenic Non-Epileptic Seizure?

Answer 33

1. H/O head trauma (up to 75%)
2. H/O epilepsy
3. H/O physical, sexual (50%) or emotional trauma
4. preexisting psychiatric disorder

Question 34

what is the difference between internal and external motivation?

Answer 34

1. the symptoms serve to keep internal conflicts outside of conscious awareness primary gain = internal motivation

for example, conflict about aggression might be symbolically expressed in a paralyzed arm

2. patient received benefits by being in sick role and thus is able to get out of obligations and stressful life situations such as work, jail time, secondary gain = external motivation

thus, can get out of disliked responsibilities and may get increased attention from caretakers

secondary gain is NOT consciously sought in conversion d/o

Question 35

what is the prevalence of conversion disorder?

Answer 35

2-3 female: male

5% of referrals to neurology clinics

2-5/100,000 per year have persistent conversion sx

Question 36

what is the course of conversion disorder? aka when do certain symptoms peak?

Answer 36

non-epileptic attacks peak in 20’s

motor sx peak in 30’s

Question 37

what are the risk factors for developing conversion disorder?

Answer 37

1. maladaptive personality traits
2. H/O childhood abuse and neglect
3. stressful life events
4. neurological diseases that cause similar sx increase risk

Question 38

what is primary gain?**

Answer 38

symptoms of conversion disorder serve to keep internal conflicts outside of conscious awareness

internal motivation

if i’m not an aggressive person but i get so angry i want to punch someone, my right arm becomes paralyzed so now i don’t have to worry about that i don’t like aggression but i’m feeling aggressive

Question 39

what is secondary gain?**

Answer 39

symptoms from conversion disorder allow patients to get out of obligations and stressful life situations

external motivation

even these secondary gains though are NOT actively sought in conversion disorder

Question 40

what is La Belle Indifference?

Answer 40

inappropriately not caring about symptoms

maybe you’re visually impaired from conversion disorder and someone with la belle indifference doesn’t really care and they just go along like everything is fine

Question 41

what is astasia/abasia?

Answer 41

a staggering, ataxic gait

lots of jerky movements of upper extremities and difficulty standing without help

seen often with conversion disorder

Question 42

what is the prognosis for someone with conversion disorder?

Answer 42

relatively good if hort duration of sx and an acceptance of dx

prognosis could be a little iffy if there’s a comorbid physical disease
or they’re getting disability benefits from the disorder

Question 43

how do you manage conversion disorder?

Answer 43

1. thorough medical workup to rule out underlying medical cause

neurological diseases such as myasthenia gravis, multiple sclerosis, optic neuritis, AIDS can be mistaken for conversion disorder

2. psychotherapy: coping skills

conversion d/o usually resolves spontaneously, but can also be facilitated by therapy, helping patient verbally deal with stress

Question 44

when should you not make the diagnosis of a conversion disorder?

Answer 44

1. if there’s no clinically significant distress or disability
2. if symptoms occur within a cultural context

Question 45

what is body dysmorphic disorder?

Answer 45

the strongly held belief that the body is misshapen or defective in some way; it can be imagined or an exaggeration of something already there

this is now classified as part of Obsessive Compulsive and Related Disorders

diagnosis often missed – explained away as part of depression or social phobia

Question 46

how prevalent is body dysmorphic disorder?

Answer 46

average age of patients is 30 yo

symptoms usually first develop in adolescent or young adulthood in patients from middle class families

male = female

prevalence 2.4% –> 9-15% of dermatology pts, 7-8% of cosmetic surgery pts, 10% requesting oral/maxillofacial surgery

Question 47

what is the clinical presentation of someone with body dysmorphic disorder?

Answer 47

1. patients shy, self-absorbed, self-centered; patients severely curtail social and occupational activities because of being concerns about others noticing the flaws
2. patients distressed about imagined defect; they describe preoccupation with the “flaw” as “torturing” and “tormenting”
3. most common emphasis on facial features
4. overly concerned about others noticing the “flaw”
5. associated with childhood abuse and neglect
6. up to 33% remain housebound

up to 20% attempt suicide

~ 50% depressive disorders

~ 75% psychotic symptoms

Question 48

what is the course of body dysmorphic disorder?

Answer 48

starts in teens (66%)

onset usually gradual

usually chronic if left untreated but can improve with treatment

suicide attempts, comorbidity, and gradual onset more likely with onset in teens

sometimes more severe psychopathology like schizophrenia can develop

Question 49

how do you manage body dysmorphic disorder?

Answer 49

1. treat coexisting anxiety, depression

2. serotonin specific antidepressants

Question 50

what is factitious disorder?

Answer 50

physical or psychological symptoms that are intentionally produced with the sole objective to assume the role of patient –> this differentiates it from the somatic symptom disorders we talked about

patients are conscious of their behaviors but may not be conscious of motivations

there’s factitious disorders with predominantly physical signs and symptoms
and also factitious disorder with predominantly psychological signs and symptoms

Question 51

what are the clinical features of someone with factitious disorder with physical signs and symptoms?

Answer 51

intentional production of physical symptoms that’s motivated by the psychological need to assume the role of the sick person

1. excellent at feigning symptoms; don’t want to release medical records to confirm anything
2. motivation to assume sick role
3. commonly feigned illnesses include cancer, diarrhea, epilepsy, hypoglycemia, FUO, hematuria, kidney stones
4. use “props” to support illnesses
5. grid-iron abdomen = multiple scars on abdomen from multiple exploratory surgeries
6. demanding/ difficult in hospital
7. specify medication they want

Question 52

what is Munchausen’s syndrome?

Answer 52

an extreme form of factitious disorder with physical signs and symptoms

these patients are pathological liars and often wander from hospital to hospital

they have recurrent illnesses that won’t change after appropriate treatment and have a pretty good knowledge base of medical issues and are eager for procedures to be done/dictate their own treatment

often unmarried middle aged men who lack stable relationships

Question 53

what are the clinical features of factitious disorder with psychological signs and symptoms?

Answer 53

1. severely depressed and suicidal due to some unidentifiable event
2. symptoms worse during observation
3. hallucinations
4. many have personality disorders
5. may receive high dose psychotropics because they aren’t “getting better” with smaller doses because they don’t actually have anything

Question 54

what is Factitious Disorder Not Otherwise Specified?

Answer 54

Factitious Disorder by Proxy = Intentionally produce symptoms in another person under their care

usually a parent and a child

Question 55

what is the course and prognosis of someone with factitious disorder?

Answer 55

begins early adulthood; onset of illness may follow real illness or loss

difficulty sustaining jobs and interpersonal relationships due to chronic hospitalizations and always seeking treatment

variable prognosis; sometimes they keep getting sick and other times it’s just a 1 time thing

Question 56

how do you manage factitious disorder?

Answer 56

1. no specific treatment has been found to be effective and very difficult
2. confrontation of patient controversial – do not want to cause patient to “lose face”

the paradox is that they deny their true illness

3. focus on management and not cure

they rarely participate in therapy

Question 57

what is malingering?

Answer 57

the production of physical or psychological symptoms that are false or grossly exaggerated, and intentionally produced for some external incentive such as avoiding military duty or jail or obtaining drugs

the external incentive is what separates it from factitious disorder

occurs more frequently in situations involving men

Question 58

what are the clinical features of someone with malingering?

Answer 58

1. express subjective, vague symptoms like headaches, vertigo, abdominal pain, back pain
2. consider diagnosis if:
   - person referred by attorney
   - discrepancy between the patient’s symptoms and your objective findings
   - lack of cooperation; they’re not going to let you get records from other providers
   - antisocial personality disorder
3. ALWAYS an external motivation involved
   ex. avoids difficult/dangerous situation or receive compensation or retaliation

Question 59

what causes malingering?

Answer 59

there are no predisposing factors known

however, it is associated with antisocial personality disorder

Question 60

what is the course and prognosis of malingering?

Answer 60

symptoms will continue as long as patient receives benefits….once rewards obtained, sx abate

uncooperative with treatment

if they’re confronted they’ll just resort to doctor-shopping until they find one who does what they want

Question 61

how do you detect malingering?

Answer 61

waste

Ⓦithhold information deliberately

Ⓐntisocial

Ⓢomatic findings are changeable

Ⓣreatment compliance is erratic

Ⓔxternal gains

Question 62

how do you treat malingering?

Answer 62

1. successful detection
2. important to preserve patient-physician relationship
3. intense treatment may allow patient to give up symptoms without losing face
4. treatment of coexisting disorders

Question 63

A 25-year-old man comes to your office for a follow-up visit. He had been in a motor vehicle accident one week ago, and was subsequently diagnosed by the Emergency Department physician as possibly having a mild “whip-lash” injury. Today, the patient is claiming that his symptoms have worsened, and he is refusing to take off his neck brace stating he cannot tolerate the pain.

You discover upon leaving the examining room that one of your colleagues observed this patient in the parking lot walking normally without his neck brace on.

What is your diagnosis?

Answer 63

malingering

Question 64

A 32-year-old woman comes to your office with complaints of nausea and diarrhea for the past six months. She says she has been to multiple specialists, none of whom have been able to find a physiological cause for her symptoms. She says one doctor even had the nerve to recommend she seek some counseling. Upon further questioning, you learn that she has been sickly most of her life with asthma, headaches, etc.

What is your diagnosis?

How would you approach this patient?

Answer 64

somatic symptom disorder

Question 65

You are referred a patient with a 3-year history of multiple vague health and cognitive complaints including pain, nausea, memory and concentration difficulties, and fatigue. Despite an exhaustive battery of tests, no medical basis has been found for the patient’s symptoms.

Additionally, the reported severity of her complaints appears grossly out of proportion given gathered information and your own clinical observations. She does appear genuinely and significantly distressed by her reported issues but otherwise denies depressive symptoms.

After meeting with the patient, reviewing medical records (which include valid performance on neuropsychological validity testing), and interviewing multiple collateral sources, you come to the opinion that the patient is not intentionally falsifying or exaggerating her symptoms.
The patient does claim that she is no longer able to work due to the severity of her difficulties and states that she intends to file for disability.

Answer 65

somatic symptom disorders

she’s not intentionally exaggerating or falsifying anything and she’s genuinely stressed and does have somatic symptoms

Question 66

what’s the difference in the symptom production and motivation in somatic symptom disorder, factitious disorders and malingering?

Answer 66

SSD = unconscious symptom production and unconscious motivation

factitious disorder = conscious symptom production but unconscious motivation

malingering = conscious symptom production and conscious motivation