Transcript Psychiatric Classification

Somatoform & Factitious
Disorders
(Thanks to:
Drew Bradlyn, Ph.D.)
Somatoform Disorders
Key Feature:
 Types
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Somatization Disorder
Conversion Disorder
Hypochondriasis
Somatoform Pain Disorder
Body Dysmorphic Syndrome
Undifferentiated Somatoform Disorder
Quick but irrelevant
Body Dysmorphic Disorder
 Pain Disorder
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Somatization Disorder:
Diagnostic Features
Key feature: Multiple, unexplained
symptoms
 Criteria
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4 pain
2 GI
1 sexual/reproductive
1 pseudoneurological
If within a medical condition, XS sxs
Lab abnormalities absent
Not intentionally feigned or produced
Somatization Disorder:
Associated Features
Colorful, exaggerated terms
 Inconsistent historians
 Depressed mood and anxiety symptoms
 Chronic, rarely remits completely
 Lifetime prevalence: 0.2% - 2% F
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< 0.2% among men
Hypochondriasis:
Diagnostic Features
Key feature: fear/belief--disease
 Criteria
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Unwarranted fear or idea persists despite
reassurance
 Clinically significant distress
 Not restricted to appearance
 Not of delusional intensity
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Hypochondriasis:
Associated Features
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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
Conversion Disorder:
Diagnostic Features
 Key
Feature:
 Criteria
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Symptoms are preceded by stressors
Symptoms are not intentionally feigned or produced
No neuro, medical, substance abuse or cultural
explanation
Must cause marked distress
Conversion Disorder:
Associated Features
In 10 - 50% ->physical disease
 F > M (varies from 2:1 to 10:1)
 Symptoms do not conform… Prevalence
ranges from 11/100,000 to 300/100,000
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Outpatient mental health: 1 - 3%
“la belle indifference”
 Histrionic
 Figure of identity
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More on Somatoform
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Hypochondriasis is most common (M = F)
Somatization disorder lifetime risk for F <3%
Conversion and somatoform pain d/o F > M, but
found in <1% 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
Factors that Facilitate Somatization
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Gains of illness
Social isolation
Amplification
Symptoms used as
communication
Physiologic concomitants
of psych d/o
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Cultural attitudes
Religious factors
Stigmatization of
psych illness
Economic issues
Symptomatic
treatment
Ford (1992)
Differential
Differential
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Things that affect:
Concrete findings
 Perception of Illness
 Presentation of Illness
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“Concrete”
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Diseases that don’t follow the rules
Perception
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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
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Key Feature: Sx’s Intentionally produced
to assume sick role
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Types
Factitious Disorder
 Factitious Disorder by Proxy
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Factitious Disorder:
Associated Features
M>F
 Hospital/healthcare workers
 External incentives absent
 Distinguished from somatoform…
Distinguished from malingering…
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Review Question
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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.
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What’s going on!
Review Question
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42 YO man presents to a PMD saying that he believes
he has Lyme’s 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 didn’t 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?
What’s going on?
Review Question
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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 doesn’t 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.