Somatoform & Factitious Somatoform & Factitious DisordersDisorders

(Thanks to:(Thanks to:

Drew Bradlyn, Ph.D.)Drew Bradlyn, Ph.D.)

Somatoform DisordersSomatoform Disorders

Key Feature: Key Feature: TypesTypes

Somatization DisorderSomatization Disorder Conversion DisorderConversion Disorder HypochondriasisHypochondriasis Somatoform Pain DisorderSomatoform Pain Disorder Body Dysmorphic SyndromeBody Dysmorphic Syndrome Undifferentiated Somatoform DisorderUndifferentiated Somatoform Disorder

Quick but irrelevantQuick but irrelevant

Body Dysmorphic DisorderBody Dysmorphic DisorderPain DisorderPain Disorder

Somatization Disorder:Somatization Disorder:Diagnostic FeaturesDiagnostic Features

Key feature: Multiple, unexplained Key feature: Multiple, unexplained symptomssymptoms

CriteriaCriteria 4 pain 4 pain 2 GI 2 GI 1 sexual/reproductive1 sexual/reproductive 1 pseudoneurological1 pseudoneurological If within a medical condition, XS sxsIf within a medical condition, XS sxs Lab abnormalities absentLab abnormalities absent Not intentionally feigned or producedNot intentionally feigned or produced

Somatization Disorder: Somatization Disorder: Associated FeaturesAssociated Features

Colorful, exaggerated termsColorful, exaggerated terms Inconsistent historiansInconsistent historiansDepressed mood and anxiety symptomsDepressed mood and anxiety symptomsChronic, rarely remits completelyChronic, rarely remits completelyLifetime prevalence: 0.2% - 2% FLifetime prevalence: 0.2% - 2% F

< 0.2% among men< 0.2% among men

Hypochondriasis:Hypochondriasis:Diagnostic FeaturesDiagnostic Features

Key feature: fear/belief--disease Key feature: fear/belief--disease CriteriaCriteria

Unwarranted fear or idea persists despite Unwarranted fear or idea persists despite reassurancereassurance

Clinically significant distressClinically significant distressNot restricted to appearanceNot restricted to appearanceNot of delusional intensityNot of delusional intensity

Hypochondriasis:Hypochondriasis:Associated FeaturesAssociated Features

Medical history often presented in great detailMedical history often presented in great detail Doctor-shopping commonDoctor-shopping common Patient may believe s/he is not receiving proper Patient may believe s/he is not receiving proper

carecare Patient may receive cursory PE; med condition Patient may receive cursory PE; med condition

may be missedmay be missed Negative lab/physical exam resultsNegative lab/physical exam results M = FM = F Primary care prevalence: 4 - 9%Primary care prevalence: 4 - 9% May become a complete invalidMay become a complete invalid

Conversion Disorder:Conversion Disorder:Diagnostic FeaturesDiagnostic Features

Key Feature: Key Feature: CriteriaCriteria

Symptoms are preceded by stressorsSymptoms are preceded by stressors Symptoms are not intentionally feigned or producedSymptoms are not intentionally feigned or produced No neuro, medical, substance abuse or cultural No neuro, medical, substance abuse or cultural

explanationexplanation Must cause marked distressMust cause marked distress

Conversion Disorder:Conversion Disorder:Associated FeaturesAssociated Features

In 10 - 50% ->physical disease In 10 - 50% ->physical disease F > M (varies from 2:1 to 10:1)F > M (varies from 2:1 to 10:1)Symptoms do not conform… Prevalence Symptoms do not conform… Prevalence

ranges from 11/100,000 to 300/100,000ranges from 11/100,000 to 300/100,000Outpatient mental health: 1 - 3%Outpatient mental health: 1 - 3%

““la belle indifference” la belle indifference” HistrionicHistrionicFigure of identityFigure of identity

More on Somatoform More on Somatoform

Hypochondriasis is most common (M = F)Hypochondriasis is most common (M = F) Somatization disorder lifetime risk for F <3%Somatization disorder lifetime risk for F <3% Conversion and somatoform pain d/o F > M, but Conversion and somatoform pain d/o F > M, but

found in <1% of populationfound in <1% of population Higher incidence in medical settings (?50%)Higher incidence in medical settings (?50%) 10% of med-surg patients have no physical 10% of med-surg patients have no physical

evidence of diseaseevidence of disease Costs of evaluating and treating = $30 billion in Costs of evaluating and treating = $30 billion in

19911991

Factors that Facilitate SomatizationFactors that Facilitate Somatization

Gains of illnessGains of illness Social isolationSocial isolation AmplificationAmplification Symptoms used as Symptoms used as

communicationcommunication Physiologic concomitants Physiologic concomitants

of psych d/oof psych d/o

Cultural attitudesCultural attitudes Religious factorsReligious factors Stigmatization of Stigmatization of

psych illnesspsych illness Economic issuesEconomic issues Symptomatic Symptomatic

treatmenttreatment

Ford (1992)Ford (1992)

DifferentialDifferential

DifferentialDifferential

Things that affect:Things that affect:Concrete findingsConcrete findingsPerception of IllnessPerception of IllnessPresentation of IllnessPresentation of Illness

““Concrete”Concrete”

Diseases that don’t follow the rulesDiseases that don’t follow the rules

PerceptionPerception

Psych diseases:Psych diseases:DepressionDepressionAnxietyAnxietyPsychosisPsychosisOther, weirder stuffOther, weirder stuff

PresentationPresentation

MalingeringMalingeringFactitious DisorderFactitious DisorderMore normal thingsMore normal things

Factitious DisorderFactitious Disorder

Key Feature: Sx’s Intentionally produced Key Feature: Sx’s Intentionally produced to assume sick roleto assume sick role

TypesTypesFactitious DisorderFactitious DisorderFactitious Disorder by ProxyFactitious Disorder by Proxy

Factitious Disorder:Factitious Disorder:Associated FeaturesAssociated Features

M > FM > FHospital/healthcare workersHospital/healthcare workersExternal incentives External incentives absentabsent Distinguished from somatoform… Distinguished from somatoform…

Distinguished from malingering…Distinguished from malingering…

Review QuestionReview Question

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

What’s going on!What’s going on!

Review QuestionReview Question 42 YO man presents to a PMD saying that he believes 42 YO man presents to a PMD saying that he believes

he has Lyme’s disease. His main sx is chronic and he has Lyme’s disease. His main sx is chronic and persistent headaches. He explains that 2 courses of oral persistent headaches. He explains that 2 courses of oral amoxicillin and ceftriaxone have not helped, and he is amoxicillin and ceftriaxone have not helped, and he is asking for oral antibiotics. The patient is persistent: asking for oral antibiotics. The patient is persistent: saying last doctor didn’t know what he was doing, and saying last doctor didn’t know what he was doing, and that his wife is getting very frustrated with him. that his wife is getting very frustrated with him. History reveals no risk factors, exam is unremarkable, Lyme titer is History reveals no risk factors, exam is unremarkable, Lyme titer is

negative.negative.

What is the most likely diagnosis?What is the most likely diagnosis?What’s going on? What’s going on?

Review QuestionReview Question A neurologist consults you on a patient: he notes that he A neurologist consults you on a patient: he notes that he

has diagnosed MS in the this 35 YO woman, but is has diagnosed MS in the this 35 YO woman, but is skeptical whether she really has it. He says that her skeptical whether she really has it. He says that her major symptom is an “odd walk” which doesn’t conform major symptom is an “odd walk” which doesn’t conform to any gait deformity he has seen. to any gait deformity he has seen.

On interview, patient is pleasant. She is aware of the On interview, patient is pleasant. She is aware of the oddness of her walk, and the growing doubt among her oddness of her walk, and the growing doubt among her doctors. She cannot explain her gait, only describing a doctors. She cannot explain her gait, only describing a sense of weakness. sense of weakness.

How would you approach this patientHow would you approach this patientWhat would you ask to help diagnose the case. What would you ask to help diagnose the case.