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Flashcards in Lec 84 Somatic Symptoms Deck (31)
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How do you categorize somatoform disorders?

by level of conscious/unconscious motivation

by level of conscious/unconscious symptoms


What is malingering?

pt consciously fakes disorder in order to attain specific [external] gain like avoiding work, obtaining compensation


What is a factitious disorder?

pt consciously creates physical/psych symptoms in order to assume "sick role" to get medical attention [internal gain]


What is somatoform disorder?

physical symptoms with no identifiable physical cause, both illness production and motivation are unconscious drives; symptoms not intentionally produced or feigned


What are DSM criteria for somatic symptom disorder?

- one or more somatic symptoms [including pain] that are distressing or cause significant disruption daily life

- excessive thoughts, feelings, behaviors related to somatic symptoms as manifested by:
- persistent thoughts about seriousness of symptoms
- high level anxiety about health
- excess time/energy devoted to health concerns

state of being symptomatic persists > 6 mo although any one symptom may not be continuous


What are some common behaviors in somatic symptom disorder?

- high level worry of illness even when evidence to contrary
- health concerns = central role in life, feature of identity
- high level med care utilization
- may seek care from multiple docs for same symptoms
- often unresponsive to med interventions
- may refuse mental health referral


What is epidemiology of somatic symptom disorder?

female > males
prevalence 5-7%
common in lower SES


What is course of illness somatic symptom disorder?

begins in adolescence through mid 20s
chronic illness with fluctuations in freq and diversity
rarely totally remits


If you see pt < age 30, many physical complaints over period of years and result in treatment being sought or significant impairment in functioning
- multisystem symptoms

somatic symptom disorder


What is differential diagnosis somatic symptom disorder?

MS, SLE, hemochromatosis, psych disorders, malingering


What is etiology of somatic symptom disorder?

unconscious need to be ill = symptoms are learned behavior and way of controlling environment

- chaotic lives, history of abuse, inability to verbalize distress
- co-morbid with personality disorder, antisocial PD, alc dependence

- cognitive deficits suggest bilateral frontal lobe dysfunction
- difficulty information processing = "hysterical"


What are genetics of somatic symptom disorder?

- diagnosed in 20% of female 1st degree relative women w/ disorder


What is treatment for somatic symptom disorder?

prevent adoption of sick role

regularly scheduled appts with consistent reassurance

limit invasive tests, avoid unnecessary meds

treat co-morbid psych disorders
sensitive referral for psychotherapy


What is conversion disorder?

- one or more symptoms of altered voluntary motor or sensory function = sudden loss of function [paralysis, blindness, mutism]

- often following acute stressor

- pt aware but may be indifferent toward symptoms

symptoms involuntary, often respond to suggestion

initiation/exacerbation preceded by conflicts/stressors

not limited to pain or sexual dysfunction


35 year old woman who presents with acute onset blindness after walking in on husband with another woman

What should you think?

conversion disorder


22 year old man who develops atypical chest pain on the anniversary of his father’s death from an MI. Admitted to CCU, where he can grieve and at same time be excused from the demands of his ongoing life

What should you think?

conversion? or malingering?


What are some types of presentations that can occur in conversion disorder?

motor = weakness/paralysis, abnormal movement

sensory = altered sensation, vision, hearing

abnormal generalized limb shaking with loss of consciousness

episodes of unresponsiveness


What is epidemiology of conversion disorder?

females, adolescents, young adults

lower SES/education
lack of psychological sophistication


What is course of conversion disorder?

onset anytime through lifespan = usually late adolescence/early adulthood

acute/self-limited, usually resolve by discharge; 25% relapse w/in 1 yr

better prognosis for blindness/paralysis; worse for seizure/tremor

single episode usually 1 symptoms but longitudinally can have other conversion symptoms


What is differential for conversion disorder?

MS, myasthenia gravis, polio, epiletpiform seizure, guillain barre, other myopathies

- factitious disorder or malingering if definite evidence of feigning


What is etiology of conversion disorder?

- history of childhood abuse/neglect
- limbic areas might override activation motor/sensory cortices


What is treatment for conversion disorder?

treat co-morbid psych illness
rule out physical illness
give reassurance/relaxation
direct confrontation not recommended
deal with underlying conflict/interpersonal relationships


What is factitious disorder?

motivation presumed to be unconscious, related to desire to assume sick role

consciously create physical/psych symptoms to assume "sick role" and get medical attention

external incentives for the behavior absent [economic gain, avoid legal responsibility, etc]

usually reject psych interventions


What is etiology of factitious disorder?

women > men
age 20-40s
may have health related jobs or training
high prevalence co-morbid psych disorders --> malingering, substance abuse, PD

desire to receive empathetic support

early childhood abuse, emotional deprivation

triggered by recent stressor

unusually seeking invasive tests


What is munchausen?

chronic factitious disorder wtih physical signs and symptoms
characterized by history multiple hospital admissions and willingness to receive invasive procedures

co-morbid with antisocial PD

single males, 40s


What is treatment for fictitious disorder?

avoid neg rxns toward pt
psych consult, delicate confrontation, collaborative treatment
treat comorbid disodrers


What is munchausen syndrome by proxy [factitious disorder imposed on another]

- falsification psycholigcal signs/symptoms in another
indicidual presents another to others as ill, impaired, injured even in absence of obvious external rewards

motivation = sick role by proxy = form of child/elder abuse


Is malingering a psychiatric disorder?



How do you treat malingering?

understand motivations for symptom production

be prepared for defensive rxn

family/educational/occupational interventions may reduce motivation to malinger


What is hypochondriasis?

pre occupation with fear of having serious disease based on misinterpretation of body signs/symptoms

belief not of delusional intensity and not restricted to concern about appearance

equal men/women