Transcript Somatoform Illness and Malingering

Somatoform Disorders and
Malingering
Vicken Y. Totten MD
7 December 2011
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Goals and Objectives
To review the traditional “contract”
between physicians and patients
To review illness and healing
To review management of
somatoform and factitious illnesses.
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The contract
Patients feel “dis-ease” and want to feel
“at ease”
Patients want physicians to relieve their
“dis-ease” & provide them with
wellbeing
Physicians want to “diagnose” first, treat
second and comfort when they can.
Physicians want patients to actively seek
and work towards their own wellbeing.
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The disconnect
Patient dis-ease may not be caused by an illness
The patient’s illness may not fit within the
doctors paradigms
Physicians are altruistic; they wish to “cure”
and “help”; when they cannot, they are
frustrated.
Frustrated physicians are uncomfortable and
tend to blame the patient for the illness
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Examples
Hysteria – a disease of the uterus
Treatment – hysterectomy & castration
Dysmenorrhea – caused by a woman’s nonacceptance of her place in society.
Treatment – psychotherapy
Fibromyalgia, reflex sympathetic dystrophy,
cyclical vomiting, many psychiatric disorders,
temporal lobe seizures, ergot poisoning and
many more have been considered somatoform.
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Differential
Munchausen's
Factitious disorder
Somatoform disorder
Malingering
Hypochondriasis
Conversion disorder
Chronic pain syndromes
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Somatization per Rosen
 “Somatization refers to a tendency to experience and
communicate psychological distress as physical
symptoms in the absence of identifiable pathology.”
 Symptoms neither feigned nor under the voluntary
control.
 Often associated with depression & anxiety
 May have “real” diseases, but complaints are out of
proportion to the physical findings.
 # sx rather than specific symptom indicates
somatization
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Concomitant Psychiatric disorders
 Women (5); men (3) unexplained somatic complaints > diagnosable psychiatric disorder 2x general populace.
 Somatizers often alexithymiic
 (“without words for mood”), resulting in alternative
(somatic) forms of expression.[21] They steadfastly
insist that their symptoms are caused by serious
physical disorders even in the presence of conclusive
evidence to the contrary.[8] Somatization may be
unconsciously motivated by a desire to assume the
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The “sick role”
Privileges and responsibilities.
Privileges: care from others; release from
normal obligations; absolution from
blame for their condition.
Responsibility: to actively try to get well;
comply with recommendations; respond
to treatment
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Age effects
In children: headache, low energy levels,
and recurrent abdominal pain are
common; not usually indicative of severe
social, psychiatric or emotional illness.
Pronounced polysymptomatic
somatization may indicate increased risk
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History
DSM-III and DSM-IV as “hysterical” and
“hypochondriacal” neuroses.
4 specific disorders
(1) somatization disorder,
(2) conversion disorder,
(3) pain disorder,
(4) hypochondriasis.
Prevalence of 0.06 to 2% among the general
population and up to 9% among hospitalized
patients
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CRITERIA for Somatization (Rosen)
 Hx of medically unexplained physical symptoms
beginning before the age of 30 years.
 All of the following:
 Pain in at least 4 body sites (e.g., head, abdomen, back, joints,
chest) or functions (e.g., during menstruation, during
urination)
 > 2 GI symptoms other than pain
 1 or more sexual or reproductive symptom other than pain
(e.g., sexual indifference, irregular menses)
 1 or more sx or deficit suggesting a neurologic condition not
limited to pain (e.g., paralysis, lump in the throat, blindness)
 Sx not explainable by any known medical condition or, are out
of proportion to what might be reasonably expected.
 The symptoms must not be intentionally produced or feigned.
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Impact
Only 33% of patients recover during 10to 20-year follow-up,
New symptoms surface at least q year
A “lifetime of suffering,” -> normal life
span
Health care costs 9x > than unaffected
patients
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Associations:
socioeconomic groups,
alcoholism and other addictions
poor education;
occupational, interpersonal, and marital
problems.
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Organic Diseases That May Be Mistaken
For Somatoform Disorders
 Endocrine disorders: hyperparathyroidism, thyroid
disorders, Addison's disease, insulinoma, panhypopituitarism
 Poisonings: botulism, carbon monoxide, heavy metals
 Porphyria
 Multiple sclerosis
 Systemic lupus erythematosus
 Wilson's disease
 Myasthenia gravis
 Guillain-Barre syndrome
 Uremia
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Conversion Disorder
AKA hysterical neurosis, conversion type
Often a single physiologically impossible
condition.
Not voluntary
Most common in ED are pseudo-neurologic:
pseudo seizures, syncope or coma, and paralysis
or other movement disorders.
Belle indifference
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Pain Disorder
Aka somatoform pain disorder
Distressful pain that
is not intentionally feigned
persistent in nature,
limits daily function,
involves one or more organ systems,
cannot be pathophysiologically explained.
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Associated features
frequent physician visits
excessive use of analgesics,
requests for surgery, and
eventually the role of permanent invalid
after the pain has forced the patient to
discontinue gainful employment.
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Hypochondriasis
 From “regio hypochondriaca” because of the presumed splenic seat
of the disorder
 4 characteristics:
 physical symptoms disproportionate to demonstrable organic disease;
 a fear of disease with a conviction that one is sick, leading to “illnessclaiming behavior” (a compulsive insistence on being considered a
physical cripple); (
 preoccupation with one's own body;
 persistent and unsatisfying pursuit of medical care (doctor shopping)
with a history of numerous procedures and surgeries and eventual
return of symptoms.
 Exaggerated awareness of normal physical signs or sensations
 Does not respond to reassurance.
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Hypochondriasis
Common (4-9% o general practice)
Expert at defeating the doctor
Age peaks: 30s-40s
Often “health nuts”
Induce negative feelings in physicians.
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Somatoform and
Hypochondriasis
Best care is a single, identified (and
very patient!) primary care physician
who can give the patient lots of
attention and regular visits.
21
Factitious Disease and
Malingering
We thank our readers sagacious
For reading our research auspicious
When the patient is hot
But the urine is not
The urine says “fever factitious”
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Differentiating malingering from
somatoform illness
Deliberate deception rather than
unconscious.
Often associated with antisocial
personality disorder
Deliberately hard to confirm their
claims
More common in health care
professionals
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Factitious Disorders
Usually not initially considered
Dx delayed
Dx confounded by concomitant real
illness
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DX made when:
(1) the patient is accidentally
discovered in the act,
(2) incriminating items are found,
(3) laboratory values suggest nonorganic etiology, or
(4) the diagnosis is made by exclusion.
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Malingering
Malingering for financial or drug gain
is criminal behavior
Documentation must be made with
care.
When coupled with drug seeking, may
list many drug allergies.
Internet searchers make patients more
sophisticated.
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Characteristics of Malingering
Often has a medicolegal context
Marked discrepancy between the person’s
claimed stress or disability and objective
findings.
Poor cooperation during the diagnostic
evaluation m, or poor compliance with
prescribed treatments.
Person exhibits or has a Hx of antisocial
behaviour.
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Management
 Depression heralds better response than personality
disorder
 Confrontation rarely effective
 Therapeutic double bind: notify patient “that a
factitious disorder may exist. The patient is further
told that failure to respond fully to medical care
would constitute conclusive evidence that the
patient's problem is not organic but rather
psychiatric. The problem is therefore reframed or
redefined in such a way that (1) symptoms and their
resolution are both legitimized and (2) the patient
has little choice but to accept and respond to a
proposed course of action or seek care elsewhere.”
 This approach is not appropriate for the ED
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Munchausen's
Essentially untreatable. Successful
treatment is reportable.
So a thorough exam (often do not want
complete exam)
Set limits, rule out life-threats.
The confronted patient usually
disappears, only to reappear elsewhere
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Munchausen's Syndrome by
Proxy (MSBP)
Adult caregivers deliberately feign or
create illness in a dependant child.
Primary concern is to protect the child.
At time of diagnosis and confrontation,
there is high risk for maternal suicide.
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Disposition
Out of home care for child victims of
MSBP
Children returned to the home have
20% risk of death.
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KEY CONCEPTS
 2 broad diagnostic categories:
 (1) those with obvious secondary gain (malingering), who control
their actions,
 (2) those with a motivation of achieving the sick role (factitious
disorders), who cannot control their actions.
 ED management
 a caring attitude
 a search for objective clinical evidence of treatable medical or
psychiatric illness.
 Avoid unnecessary tests, medications, and hospitalizations in
the absence of objective evidence of a medical or psychiatric
disease
 Refer for ongoing primary care.
 Victim protection takes first priority.
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The Difficult Patient
Aka the “heart-sink patient”
More common in the ED than general
medical practice
Usually have significant personality
disorders or psychiatric disorders
Several classifications
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One classification
Dependent patients
Entitled patients
Intractable patients
Self-destructive patients
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Dependant patients
Excessive need for attention,
reassurance, analgesia
Use helplessness and seduction as
strategies.
Physician initially feels special, then
drained and frustrated.
Patient needs increase when ultimately
rejected
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Dependent patients, traditional
diagnostic categories
Personality disorders: dependent, histrionic,
borderline personality
Malingerers, chronic psychiatric patients
Management: Try to view the patient's
neediness as a symptom. Be supportive while
setting limits on patient expectations.
Follow-up with appropriate, consistent
physician.
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Entitled Patients
Fear of loss of power causes entitled
behavior.
Uses intimidation, name dropping,
hostility, and threats.
Physician feels intimidated, angry,
sometimes inadequate.
Potential for litigation.
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Entitled Patients
Personality disorders: paranoid,
narcissistic
 Substance abusers
VIPs
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Entitled Patients (Management)
 Be supportive of entitlement to good
care while setting limits on unreasonable
demands.
Allow patients to choose between
reasonable treatment options.
Avoid power struggles.
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Intractable Patients (dx)
Excessive needs for attention met by
having unsolvable problems with multiple
visits, doctor shopping, poor compliance,
and no hope for successful treatment.
Physician feels frustrated, angry, but
fears “sharing” pessimism and missing
significant illness.
Cycle of “help me, but nothing helps.”
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Intractable Patients (behaviors)
Personality disorders: antisocial,
borderline
Malingerers
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Intractable Patients
(management)
 Distinguish from other complicated
patients, and manage appropriately.
Beware of cognitive distortions that may
obscure significant illness.
Be supportive while setting reasonable
expectations.
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Self-Destructive Patients
Disregard for own health and repeated
visits for serious illness.
Often overtly self-destructive, denying of
illness.
Physicians feel frustrated, helpless,
angry, and guilty for wishing the patient
success.
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Self-Destructive Patients
Chronically suicidal patients
Substance abusers
Borderline personality disorder
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Self-Destructive Patients
Provide appropriate medical care.
Learn to deal with own negative and
nihilistic reactions to patients.
Look for signs of depression and consider
psychiatric referral as needed.
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KEY CONCEPTS
Difficult patients may elicit negative
reactions in caregivers, resulting in
undesirable implications for both
themselves and their caregivers.
Managing the difficult patient can be
optimized by understanding the multiple
factors contributing to the impaired
physician-patient relationship.
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Key Concepts:
Behavioral classifications should be used
instead of pejorative stereotypes when
characterizing difficult behaviors.
General and specific strategies, including
understanding our own reactions, are
helpful in dealing with the impaired
physician-patient relationship.
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Key Concept
The ability to accept difficult behaviors
as symptoms and treat even the most
difficult patient with kindness is central to
providing good care while avoiding
personal frustration, medicolegal
repercussions, and physician burnout.
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Final word:
You can’t choose your patients
You CAN choose how you react
Take care of yourself first.
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