Somatoform & Factitious Disorders

30% of all patients l visits in any type of medical clinic do not have organic disorder but still have serious complains. Some of those patients having organic disorders might frequently have complains which can not be explained.

Classification of somatoform disorders

1.      Somatoform disorder

2.      Masked depression

Classification of factitious disorders

3.      Factitious disorder

4.      malingering

Somatoform Disorders

a.       Somatization disorder

b.      Conversion disorder

c.       Hypochondriasis

d.      Body dysmorphic disorder

e.       Pain disorder

f.       Undifferentiated somatoform disorder

Etiology

lPtx not aware and seeks somatic explanation

lPrimary gain = somatization is defense mechanism

This expresses an unacceptable emotion as physical symptom

lSecondary gain = symptom is useful

To get attention

To avoid responsibility

To “patients role play” as a sick person getting more attention

lHigher concordance in families and twins points to genetic vulnerability in

Somatization disorder

Pain disorder

Hypochondriasis

lMood disorder & OCD more frequent in families of patients with hypochondriasis and pain disorder

lAntisocial PD and alcoholism more frequent in families of ptx with somatization disorder

lHypochondriasis equally affect men and women

lSomatoform disorders more frequent in women

Somatization disorder: 

(also called “Briquet syndrome”) a condition in which there are multiple physical complaints, in several systems, for which no physical cause is found. It begins usually before the age of 30 years, runs a chronic course and is associated with frequent medical contact.

lSomatic complains dominate (not fear)

lHistory of at least eight physical symptoms

lNo adequate cause found

lSymptoms are chronic

lTotal remission rare

lSymptoms highly vary in different cultures

1. Hypochondriasis

lFear of serious illness dominate

lPersistent and repetitive concern

lAnancastic nature resembles to OCD

lSSRI improves the condition (as in OCD and impulse control disorders)

2. Conversion disorder

lSudden paralysis or inability to speak, see or hear

lPseudoseizures

lGlobus histericus

lParesthesias anesthesias

lTrench palsies

lFrequent in unsophisticated people

lCombined with histrionic PD

lSymptoms usually self limiting

3. Body dysmorphic disorder

lMinor or imagined defects in appearance

lUsually face or head

lTreasure house of plastic surgeons

4. Pain Disorder

lNot adequately explained by physical causes

lDisabling

lDependency

lReact to antidepressants (SSRI)

Masked Depression

Factitious disorder

(Old name: Munchausen syndrome Also known as hospital addiction It is characterized by repeated presentations for hospital treatment of an apparent acute illness with plausible symptoms and a dramatic history, all of which are false. The person may also self-injure so as to gain admission to hospital. there does not appear to be any secondary gain such as money.

lFeigning for psychological gain and attention usually medical

lAbdominal pain

lFever

lBlood in the urine

lseizures

lAdvanced medical knowledge of the patient

lGrid abdomen: remnants of multiplex unnecessary surgical interventions

lOften history of childhood disease & hospitalization where the ptx felt cared and secure

Factitious disorder by proxy

lParent or other adult feigns or induces illness in a child to gain attention

lConsidered as child abuse

lMust be reported to child welfare authorities

Malingering

lConscious simulation or exaggeration of physical or mental illness

lFinancial and other obvious gain

lNot considered as a a psychiatric illness

Case Studies

v  A 28-year-old woman with no previous psychiatric or medical history is admitted to the neurology service for evaluation of acute onset of numbness and weakness of the right side of her face and right arm and leg. Physical examination shows symmetrical 2/4 reflexes in all distributions, downgoing plantar reflexes bilaterally, and 2/5 strength in the right upper and lower extremity in all muscle groups. No atrophy or fasciculations are noted. Her gait is ataxic and staggering with extreme exaggerated movements of her arms; however, she does not fall when ambulating without assistance. Extensive neurologic workup is negative. Given the severity of her deficits, she seems unconcerned by her level of disability. The diagnosis that best captures the patient’s symptoms is which of the following?

(A) factitious disorder

(B) undiagnosed neurologic disease

(C) conversion disorder

(D) malingering

(E) somatization disorder

(C) The diagnosis of conversion disorder is most likely given that the primary symptoms are neurologic and exhaustive workup is negative for evidence of pathology that accounts for the deficits. Neurologic deficits in conversion disorder involve either motor or sensory modalities and are felt to be a result of psychological stressors. Had the symptoms been intentionally produced, the diagnosis of factitious disorder or malingering would be appropriate. If the primary incentive for the behavior was to assume the sick role, the diagnosis would be factitious disorder. If the symptoms are feigned or exaggerated for another reason, such as to gain monetary reimbursement, the diagnosis would be malingering. Somatization disorder is not appropriate in this case because the number and types of complaints do not extend past the neurologic complaints. An undiagnosed neurologic condition is a possibility, but given the extensive workup, it is less likely. It is important to note that as many as 50% of those diagnosed with conversion disorder are eventually diagnosed with a neurologic condition that could have produced the initial symptoms.

v  A54-year-old woman with a past medical history of hypothyroidism is admitted with a septic right knee. The surgery team asks you to evaluate the patient because they found that the fluid aspirate from the knee was growing a pathogen found primarily in the human mouth. They suspect the patient was injecting saliva into her knee. You evaluate the patient and find her to be pleasant and cooperative. She tells you that she has had a very tough time lately because her husband has recently been sick. Fortunately, she is a nurse and has been able to care for him at home. Lately, she admits to feeling overwhelmed and not appreciated. She has no idea what has caused the problem with her knee. You talk to the family and they tell you she is in no financial difficulty and she continues to enjoy work as a nurse. After working with you for a few weeks, she admits to injecting her knee but she cannot understand why she did. You tell the surgery team that you have diagnosed her with which of the following?

(A) malingering

(B) somatization disorder

(C) hypochondriasis

(D) conversion disorder

(E) factitious disorder

(E) Factitious disorder is an appropriate diagnosis when physical or psychological symptoms are intentionally produced in order to assume the sick role. It must be clear that these symptoms are not intentionally produced for other reasons, such as avoiding work, gaining monetary compensation, or avoiding legal issues. If any of these reasons are present, the diagnosis is malingering. Somatization disorder presents with complaints of pain, gastrointestinal symptoms, sexual dysfunction, and pseudoneurologic symptoms. The diagnosis of hypochondriasis is incorrect because this patient is not preoccupied with the idea of having a severe disease that is unrecognized despite repeated reassurances by medical personnel. Classically, people with factitious disorder are more likely to be female and to have experience in health care. Often, these patients will have numerous admissions to many different hospitals with a variety of symptoms. The psychological factors underlying this disorder are not well understood. No effective form of psychotherapy or pharmacotherapy has been identified for the treatment of factitious disorder.