Describe the symptoms seen in somatoform disorders.
What is thought to cause them?
They are unexplainable by medical test or exam, resulting in a bizarre range of diagnoses that are mostly determined by the specialty of doctor seeing the patient.
Presumably a physical manifestation of psychosocial stress. May also be just misintrepretation of normal physiological functions.
What are the negative consequences of somatoform disorders?
Impaired PDR (physician becomes frustrated, patient is dissatisfied)
Increased distress for the patient (+depression, anxiety)
Decreased quality of life
Increased health care utilization
Are somatoform disorders intentionally produced/feigned?
What is Alexithymia?
Alexithymia is the inability to describe one's emotions. Seen often in somatoform disorders (maybe it's contributory?)
What are the (DSM-5) criteria for somatic symptom disorder (Somatization disorder)?
What are its clinical features?
A somatic system that is distressing (causes anxiety, persistent thoughts about, and drains time & energy), persisting for >6mo
Patients describe themselves as sickly, give vague histories, and may exaggerate symptoms. Their records will reflect a long history of healthcare use.
How common are somatization disorders?
In what context are these patient seen?
What must be ruled out to diagnose somatization disorders?
Only 0.01% in the population, but disproportionately higher in a healthcare setting (of course)
Usually in general medical settings; most eschew or even refuse psychiatric care.
Actual diseases (with nonspecific symptoms, eg MS/MG/SLE/AIP), depression, anxiety, and the other somatoform disorders.
What are the three features that most suggest a diagnosis of somatization disorder?
1. Involvement of multiple organ systems.
2. Early onset & chronic course, without abnormal physical or structural signs.
3. Absence of laboratory abnormalities.
How should somatization disorder be treated?
Does psychotherapy help? Medication?
Schedule regular follow-ups, conduct your physical and look for objective signs of disease. However, avoid unncessary tests. Describe the pain as "stress-induced", not "in your head".
Psychotherapy isn't great (not responsive to long-term), try CBT. Medications (Antidepressants) are of limited efficacy.
What defines a conversion disorder?
How do these patients present?
Somatic symptoms preceded by acute, identifiable stressors. Be sure to distinguish from real neurological illness.
May be initially unconcerned ("la belle indifference"). Symptoms tend to conform to patients understanding of neurology.
How is conversion disorder treated?
What are some positive or negative prognostic indicators?
Conservatively; reassure, give therapy, try amytal interview or hypnosis.
Good: Clear stressor, prompt treatment, paralysis/aphonia/blindness.
Bad: Delayed treatment, seizures/tremors.
What is Pain disorder?
How is it treated?
Chronic pain thought to be caused by psychological stress. Can affect one or more areas.
Psychotherapy, the usual.
What is hypochondriasis?
How does it present, and how long is the history?
A preoccupation with illness, sub-delusional intensity.
Conviction of illness and phobia thereof. Somatic symptoms are generally not present, or are mild. 6mo history (often chronic, starting in early adulthood)
How is hypochondriasis treated?
Establish rapport, ID stressors. CBT & supportive therapy.
Serotoninergic medications may be helpful.
Who is the classic body dysmorphia patient?
In what settings do they often appear, and what drives them there?
A young adult (15-30). Occurs equally in men and women!
Dermatologic & cosmetic surgery setting, usually due to hours of obsession over a perceived flaw, especially in the face or head.
What comorbidities are often seen in body dysmorphia?
How is it treated?
Major depression disorder, personality disorders (avoidant), social phobia, OCD, substance use. Presumably Anorexia Nervosa.
Do not indulge requests for medical procedures! Try CBT and high-dose serotoninergics.
Name two deception disorders.
How can patients intentionally produce signs of disease?
Factitious disorder, malingering
Exaggeration or fabrication of symptoms, tampering with medical tests, and actual manipulations which cause harm.
What is factitious disorder?
How common is it?
Why might a patient exhibit this behavior?
Intentional appearance of illness to assume sick role (for attention, not external incentive).
About 1% of patients in psychiatric consultation?
There are theories that it relates to childhood illness (wherein a hospital is viewed as safe). It may be for self-enhancement (boost esteem).
What is Munchausen's syndrome?
Factitious disorder by proxy?
Munchausen's: A more severe and chronic form of factitious disorder, characterized by pseudologia fantastica (pathological lying)
Factitious disorder by proxy: Intentionally producing symptoms in someone under your care to act the supportive role.
Ganser's: A dissociative state wherein the patients can only answer vaguely or nonsensically. FORMERLY a factitious disorder...
What is the Ddx for factitious disorder?
How is it treated?
Actual illness (duh!), other somatoform or deceptive disorders. Try to find direct evidence of factitious disorder.
Do not indulge. ID, and address psychiatric diagnoses that may underlie the factitious disorder. Avoid countertransference, and good luck.
Describe the classic Factitious disorder patient.
A patient who works in a healthcare profession (knows how to game you & your tests), with borderline personality disorder (attention-seeking), and possibly with a history of childhood illness.
What is malingering?
When should it be considered?
Faking illness for external gain (drugs, financial compensation, litigation, dodging work/draft, etc). Symptoms often resolve upon acquiring the external good.
When presented medicolegally (eg referred by attorney), when patient is cooperative or has antisocial PD, and when the subjective & objective findings don't match.