Somatoform

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Somatoform Factitious Disorders

• (Thanks to
• Drew Bradlyn, Ph.D.)

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Somatoform Disorders

• Key Feature
• Types
• Somatization Disorder
• Conversion Disorder
• Hypochondriasis
• Somatoform Pain Disorder
• Body Dysmorphic Syndrome
• Undifferentiated Somatoform Disorder

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Quick but irrelevant

• Body Dysmorphic Disorder
• Pain Disorder

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Somatization DisorderDiagnostic Features

• Key feature Multiple, unexplained symptoms
• Criteria
• 4 pain
• 2 GI
• 1 sexual/reproductive
• 1 pseudoneurological
• If within a medical condition, XS sxs
• Lab abnormalities absent
• Not intentionally feigned or produced

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Somatization Disorder Associated Features

• Colorful, exaggerated terms
• Inconsistent historians
• Depressed mood and anxiety symptoms
• Chronic, rarely remits completely
• Lifetime prevalence 0.2 - 2 F
• lt 0.2 among men

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HypochondriasisDiagnostic Features

• Key feature fear/belief--disease
• Criteria
• Unwarranted fear or idea persists despite
  reassurance
• Clinically significant distress
• Not restricted to appearance
• Not of delusional intensity

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HypochondriasisAssociated Features

• Medical history often presented in great detail
• Doctor-shopping common
• Patient may believe s/he is not receiving proper
  care
• Patient may receive cursory PE med condition may
  be missed
• Negative lab/physical exam results
• M F
• Primary care prevalence 4 - 9
• May become a complete invalid

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Conversion DisorderDiagnostic Features

• Key Feature
• Criteria
• Symptoms are preceded by stressors
• Symptoms are not intentionally feigned or
  produced
• No neuro, medical, substance abuse or cultural
  explanation
• Must cause marked distress

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Conversion DisorderAssociated Features

• In 10 - 50 -gtphysical disease
• F gt M (varies from 21 to 101)
• Symptoms do not conform Prevalence ranges from
  11/100,000 to 300/100,000
• Outpatient mental health 1 - 3
• la belle indifference
• Histrionic
• Figure of identity

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More on Somatoform

• Hypochondriasis is most common (M F)
• Somatization disorder lifetime risk for F lt3
• Conversion and somatoform pain d/o F gt M, but
  found in lt1 of population
• Higher incidence in medical settings (?50)
• 10 of med-surg patients have no physical
  evidence of disease
• Costs of evaluating and treating 30 billion in
  1991

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Factors that Facilitate Somatization

• Gains of illness
• Social isolation
• Amplification
• Symptoms used as communication
• Physiologic concomitants of psych d/o

• Cultural attitudes
• Religious factors
• Stigmatization of psych illness
• Economic issues
• Symptomatic treatment
• Ford (1992)

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Differential
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Differential

• Things that affect
• Concrete findings
• Perception of Illness
• Presentation of Illness

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Concrete

• Diseases that dont follow the rules

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Perception

• Psych diseases
• Depression
• Anxiety
• Psychosis
• Other, weirder stuff

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Presentation

• Malingering
• Factitious Disorder
• More normal things

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Factitious Disorder

• Key Feature Sxs Intentionally produced to
  assume sick role
• Types
• Factitious Disorder
• Factitious Disorder by Proxy

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Factitious DisorderAssociated Features

• M gt F
• Hospital/healthcare workers
• External incentives absent
• Distinguished from somatoform Distinguished from
  malingering

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Review Question

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

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Review Question

• 42 YO man presents to a PMD saying that he
  believes he has Lymes disease. His main sx is
  chronic and persistent headaches. He explains
  that 2 courses of oral amoxicillin and
  ceftriaxone have not helped, and he is asking for
  oral antibiotics. The patient is persistent
  saying last doctor didnt know what he was doing,
  and that his wife is getting very frustrated with
  him.
• History reveals no risk factors, exam is
  unremarkable, Lyme titer is negative.
• What is the most likely diagnosis?
• Whats going on?

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Review Question

• A neurologist consults you on a patient he notes
  that he has diagnosed MS in the this 35 YO woman,
  but is skeptical whether she really has it. He
  says that her major symptom is an odd walk
  which doesnt conform to any gait deformity he
  has seen.
• On interview, patient is pleasant. She is
  aware of the oddness of her walk, and the growing
  doubt among her doctors. She cannot explain her
  gait, only describing a sense of weakness.
• How would you approach this patient
• What would you ask to help diagnose the case.