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126 Cards in this Set
- Front
- Back
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What is somatization?
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A tendency to experience and communicate somatic distress in response to psychosocial stress and to seek medical help for it
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What key factor allows one to differentiate between various forms of somatization?
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Whether this process is employed consciously or unconsciously
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What is the difference between somatoform disorders and factitious disorders?
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Somatoform Disorders
- unconscious production of physical signs and symptoms of illness Factitious Disorders - conscious production of complaints to assume the "sick role" |
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What is the difference between factitious disorders and malingering?
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Goal of Factitious Disorder:
- Primary Gain Goal of Malingering: - Secondary Gain |
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What is Primary Gain?
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Primary Gain
Assuming the sick role to obtain the psychological benefit of being cared for and receiving attention from nurturing, authoritative figures |
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What is Secondary Gain?
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Secondary Gain
Some benefit arising from being ill that is recognizable to the observer |
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What are examples of Secondary Gain?
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Secondary Gain
- Financial benefit in the form of disability pay - Medications such as pain pills - Decisions made by health care workers to support pending legal cases - Avoiding commitments such as military service or work obligations |
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In what health care setting do most patients with somatization present?
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Primary Care Offices
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What effect does somatization have on the health care system?
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Increases utilization of care and health expenditure
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When a patient presents with somatization, what potential underlying problems should be investigated?
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- Underlying psychiatric syndrome
- Coexisting personality disorder - Psychosocial stressor such as sexual abuse |
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What elements of history are suggestive of somatoform disorders?
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Several unconnected, exaggerated, often strange medical complaints that have been worked up by numerous physicians in the past without clear cause
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What elements of examination and laboratory studies are suggestive of somatoform disorders?
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Anxiety about these complaints, strange indifference to significant medical complaints, inconsistent physical examination or lab findings
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What age group has the highest incidence of somatization disorder?
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16-25 years of age
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What gender presents with somatization disorder more frequently?
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20:1 Female to Male Ratio
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In what socioeconomic class is somatization disorder more common?
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Lower Socioeconomic Groups
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Is there a familial pattern with somatization disorder?
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Yes, incidence is increased in first-degree relatives
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Are physical signs and symptoms consciously produced by the patient with somatization disorder?
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No
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Male relatives of patients with somatization disorder are more likely to manifest which disorders?
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Antisocial Personality Disorder (ASPD)
Substance Abuse |
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What environmental factors are prevalent among patients with somatization disorder?
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History of illness in the family or history of abusive relationships
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When should somatization disorder be suspected?
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Multiple medical complaints (diffusely positive review of systems) without any medical cause
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DSM-IV Criteria:
Somatization Disorder |
- History of seeking treatment for several physical complaints beginning before age 30 and occurring over several years
- Functional impairment results from these complaints - Presence of each of the following at any time during the course: -- 4+ Pain symptoms involving multiple sites or systems -- 2+ Gastrointestinal symptoms other than pain -- 1+ Sexual symptoms other than pain - None of these symptoms are intentionally produced or feigned |
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What is the temporal relationship between the presenting symptoms and diagnosis of Somatization Disorder?
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The symptoms must have begun before the age of 30 and have lasted for several years
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What does the differential diagnosis for somatization disorder include?
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- Mood and Anxiety Disorders with Physical Complaints
- Schizophrenia with Somatic Delusions - Other Somatoform Disorders - Factitious Disorders - Malingering - General Medical Conditions - Fibromyalgia |
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What goals should guide treatment of somatization disorder?
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- Recognition of the disorder so as to avoid further unnecessary workup
- Proper documentation of the disorder to enhance collaboration among other health care providers participating in diagnosis and management - Involvement of psychiatric services to provide appropriate support and identify comorbid disorders or psychosocial stressors - Recognition that morbidity may be somewhat alleviated with appropriate support but cure is rarely achieved |
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How should physicians optimally interact with patients affected by somatization disorder?
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Focus on psychological impact of symptoms instead of continuing medical workup or prescribing unnecessary analgesics or anxiolytics
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What is the key to successful treatment of somatization disorder?
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Formation of a therapeutic doctor-patient relationship with regular follow-up
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What is the prognosis for somatization disorder?
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Poor to fair with manifestations of the disorder recurring throughout one's life
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What is Conversion Disorder?
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Conversion Disorder
The presence of one or more motor or sensory symptoms that has a severe impact on activities of daily living or functionality |
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What age group presents with Conversion Disorder?
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Conversion Disorder may present at any age but is rare in children younger than 10 years or in the elderly.
Studies suggest a peak onset in the mid-to-late 30s |
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What gender presents with conversion disorder more frequently?
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5:1 Female to Male Ratio
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In what socioeconomic class is Conversion Disorder more common?
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Lower socioeconomic groups with rural background and poor education
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What comorbid conditions are associated with Conversion Disorder?
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Drug and Alcohol Dependence
Sociopathic Personality Somatization Disorder |
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Is there a familial pattern with conversion disorder?
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Yes
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Are physical signs and symptoms consciously produced by a patient with Conversion Disorder?
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No
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What are the likely etiologies of the physical symptoms in Conversion Disorder?
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Stress
Conflict Prior Sexual Abuse |
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What is the physiologic cause of Conversion Disorder?
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There is no known physiologic cause for the impairment in function brought on by Conversion Disorder
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In what settings do most Conversion Disorders present?
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Ambulatory Settings
Emergency Departments Neurology Services |
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DSM-IV Criteria:
Conversion Disorder |
1) Symptoms: one or more involving voluntary motor or sensory systems more than pain that resemble a neurologic or general medical condition
2) Psychological Factors: temporal relationship exists between conflict & physical symptoms 3) Unintentional nature of the symptoms 4) Exclusion of general medical conditions, substance-related cause, or culturally sanctioned behavior 5) Functionality is impaired by existence of symptoms 6) Not better explained by pain or sexual dysfunction, another mental disorder, or occurring exclusively during the course of somatization disorder |
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How do motor symptoms in Conversion Disorder typically present?
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Paralysis of an extremity
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How do sensory symptoms in Conversion Disorder typically present?
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Anesthesia (often in a non-anatomical distribution) or visual disturbances such as blindness
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Describe the onset of Conversion Disorder
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Acute and associated with psychological stress
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What subtypes of conversion disorder exist?
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Classified by type of symptoms:
- Motor - Sensory - Seizure - Mixed symptoms |
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How do the symptoms of Somatization Disorder differ from Conversion Disorder?
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Patients with somatization disorder have multiple medical complaints spread over several body systems
Conversion Disorder patients typically have a single, prominent, pseudoneurologic symptom associated with a psychological stressor |
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What features may be associated with Conversion Disorder?
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- Personality Disorders such as Antisocial, Dependent, Histrionic, or Borderline
- Mood Disorders or lack of appropriate concern - Dissociative Disorders - General Medical Conditions |
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What is included in the differential diagnosis of Conversion Disorder?
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1) General Medical Conditions
2) Neurologic Conditions such as Multiple Sclerosis or and underlying Seizure Disorder in patients with Pseudoseizures 3) Factitious Disorders 4) Malingering |
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What is the first step in treatment of Conversion Disorder?
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Rule out a general medical cause
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What treatment modalities are commonly employed for Conversion Disorder?
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- Use of suggestion with hypnosis
- Relaxation techniques - Psychotherapy - Reassurance that it will improve |
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What is the typical duration of symptoms in Conversion Disorder?
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About 2 weeks or less
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What is the prognosis for Conversion Disorder?
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Very good with high response rate to most therapeutic options when presented in a way that is suggestive of a cure.
This disorder is usually self-limiting, although it can often recur in the future under stress. |
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What age group presents with Pain Disorder?
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4th to 5th Decade
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What gender presents with Pain Disorder more frequently?
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2:1 Female to Male Ratio
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What disorders are more common in relatives of individuals with Pain Disorder?
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1) Depression
2) Pain Disorders 3) Substance-related Disorders |
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What is the theoretical benefit of having Pain Disorder?
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Assumption of the sick role alleviates psychological conflicts
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Can medical conditions exist in the setting of Pain Disorder?
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Yes. However, psychological factors exaggerate the experience of pain in relation to the underlying medical condition
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DSM-IV Criteria:
Pain Disorder |
- Severe pain in one or more anatomic sites
- Pain impairs functioning - Psychological factors affect pain onset, severity, exacerbation, and maintenance - Symptoms are unintentional - Other psychiatric conditions do not better account for the pain |
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How does Pain Disorder differ from pain presenting in Factitious Disorder or Malingering?
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Pain Disorder symptoms are not intentionally produced
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What subtypes of Pain Disorder exist?
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- Associated with psychological factors or psychological factors and medical conditions
- Acute (less than 6 months) or chronic |
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What medical conditions are most common in "Pain Disorder associated with Medical Conditions?"
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- Malignancies
- Musculoskeletal Conditions - Neuropathies |
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What is the differential diagnosis for Pain Disorder?
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1) Factitious Disorder
2) General Medical Condition 3) Somatization Disorder 4) Malingering |
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What pharmacologic interventions prove useful in treatment of Pain Disorder?
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Detoxification from pain medications or other drugs
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What pharmacologic options have shown some benefit for patients with Pain Disorder?
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- TCAs
- SNRIs: Venlafaxine, Duloxetine - MAOIs in combination with nonpharmacologic modalities - SSRIs |
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What lifestyle changes are recommended for patients with Pain Disorder?
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Resume normal daily activities
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What supportive measures exist for the treatment of Pain Disorder?
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- Encouraging the patient to subscribe to a sense of personal commitment in allaying symptoms of pain
- Counseling on learning how to manage pain behaviorally - Psychotherapy aimed at resolving underlying psychological conflicts - Relaxation techniques - Biofeedback |
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What is Hypochondriasis?
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Hypochondriasis
Preoccupation with fear of disease and conviction that subtle bodily perceptions are manifestations of severe pathology |
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What age group presents with Hypochondriasis?
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Middle to Late Age
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What gender presents with Hypochondriasis more frequently?
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Equal among males and females
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What are predisposing factors for developing Hypochondriasis?
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- Parental attitudes toward disease
- Personal past history of disease - Low socioeconomic class |
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What is a common psychodynamic explanation for Hypochondriasis?
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Displaced anxiety
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What is the core manifestation of hypochondriasis?
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Fear of having a disease stemming from misinterpreted bodily symptoms
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How do hypochondriacs respond to medical evaluation of their complaints?
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Resistant to believing that extensive medical workups show no true pathology
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How do hypochondriacs respond to reassurance provided by medical professionals?
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Poorly, often questioning physicians' credentials or seeking another opinion
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How long must symptoms exist for the diagnosis of hypochondriasis to be made?
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At least 6 months
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DSM-IV Criteria:
Hypochondriasis |
- Must be delusional in nature
- Must not be restricted to a concern about appearance as in body dysmorphic disorder - Must not be better explained by depression, OCD, anxiety, separation disorder, or another somatoform disorder |
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What subtype of Hypochondriasis exists?
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Hypochondriasis with Poor Insight
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How is Hypochondriasis with Poor Insight characterized?
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Some delusional aspect is present in that patients are not able to recognize that their preoccupations with having a serious disease are excessive in some way
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What is the differential diagnosis of Hypochondriasis?
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1) General Medical Conditions
2) Delusional Disorder (Somatic Type) 3) Normal Health Concerns |
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What 2 psychiatric conditions most frequently accompany the diagnosis of hypochondriasis?
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Major Depressive Disorder
Generalized Anxiety Disorder |
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What complications may arise from hypochondriasis?
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Inherent risks associated with repeated diagnostic testing
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What is the clinical course of Hypochondriasis?
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Waxing and waning according to psychological stressors
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What is the most important step in management of hypochondriasis?
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Obtaining and clearly documenting a complete psychosocial history?
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What is the most effective long-term treatment strategy for Hypochondriasis?
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Providing psychiatric care in conjunction with regular appointments with a primary care physician who conducts complete physical examinations as normally recommended
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What is Body Dysmorphic Disorder?
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Body Dysmorphic Disorder
Preoccupation with a specific blemish of physical appearance in a normally appearing individual |
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What age group most commonly presents with Body Dysmorphic Disorder?
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Adolescents
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What gender presents with Body Dysmorphic Disorder more frequently?
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Equal among males and females
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What are predisposing factors for developing Body Dysmorphic Disorder?
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- Parental attitudes toward appearance
- Cultural or societal attitudes toward appearance - Low self-esteem |
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To which fields of medicine do patients with Body Dysmorphic Disorder typically present?
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Primary Care Physicians
Plastic Surgeons Dermatologists |
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DSM-IV Criteria:
Body Dysmorphic Disorder |
Self-perception of ugliness or obsession with some imagined physical flaw
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Can a physical defect actually exist in a patient with Body Dysmorphic Disorder?
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Yes, but the defect is exaggerated in its contribution to deformity
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How may these obsessive thoughts be manifested in behaviors in patients with Body Dysmorphic Disorder?
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Repetitive activities such as picking at the skin, staring into a mirror, or seeking approval from others regarding appearance
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How must these preoccupying thoughts affect one's life in order to satisfy the DSM-IV criteria for Body Dysmorphic Disorder?
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Impairment of function in daily activity including avoidance of social situations due to fear of exposing the exaggerated physical flaw to others
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What key psychiatric disorder must be differentiated from Body Dysmorphic Disorder?
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Preoccupation with body image due to Bulimia or Anorexia Nervosa
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What is the differential diagnosis of Body Dysmorphic Disorder?
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1) Anorexia Nervosa
2) Social Phobia 3) Gender Identity Disorder 4) Avoidant Personality Disorder 5) Normal concerns about appearance (especially transient as in normal adolescent development) 6) Delusional Disorder 7) Other Somatization Disorders |
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What is an important initial step in management of Body Dysmorphic Disorder?
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Evaluating the patient for comorbid psychiatric conditions such as depression and anxiety that may be especially amenable to pharmacologic or psychotherapeutic interventions
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What specific treatment may be most beneficial for Body Dysmorphic Disorder?
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Individual or Group Cognitive-Behavioral Therapy aimed at psychosocial functioning and body image
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What is the indication for use of antipsychotic medication in Body Dysmorphic Disorder?
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When the preoccupation becomes delusional in character
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What is the indication for use of SSRIs in Body Dysmorphic Disorder?
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When Mood Disorders coexist
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What are Factitious Disorders?
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Factitious Disorders
Disorders occurring when an individual willfully creates signs or symptoms of medical or psychiatric disease to assume the sick role |
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Are Factitious Disorders a type of somatoform disorder?
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No, these entities are distinct categories of disorders in the DSM-IV
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What is the most severe type of Factitious Disorder?
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Munchausen Syndrome Variant
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What gender presents with Factitious Disorders more frequently?
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Male, often health care workers
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What is the most common presentation of Munchausen Syndrome variant of Factitious Disorders?
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Middle aged, unmarried, unemployed male feigning symptoms and signs of illness severe enough to be hospitalized several times while moving from one medical center to another to avoid discovery
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What does a patient gain from creating signs or symptoms of disease in order to assume the sick role?
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Benefits of the sick role may include receiving careful attention, nurturing, and support from health care professionals
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What elements of history and examination are suggestive of Factitious Disorders?
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- Vague or inconsistent medical history conveyed in a highly guarded manner
- Surprising familiarity for medical terminology or procedures in non-health care professionals due to involvement in health care - History of repeatedly moving from one health care setting to another - History in excess of physical findings - Evidence of multiple surgical scars on examination |
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DSM-IV Criteria:
Factitious Disorder |
- Physical or psychological signs or symptoms are intentionally produced or faked
- The motivation for the behavior is to assume the sick role - Secondary gains or external incentives for the behavior are absent |
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What may result as a by-product of feigning illness in Factitious Disorders?
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Iatrogenic injury, including drug intoxication or physical trauma
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What subtypes of Factitious Disorders exist?
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With psychological signs and symptoms, physical signs and symptoms, or a combination
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What is Factitious Disorder by Proxy?
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Producing signs and symptoms of illness in another individual
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What is a common example of Factitious Disorder by Proxy?
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"Munchausen Syndrome by Proxy"
A person (most often a mother) deliberately causes injury or illness to another person (most often her child), usually to gain attention or some other benefit |
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How must Munchausen Syndrome by Proxy be treated by health care workers?
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A parent deliberately causing markers of illness in her child is a form of child abuse and must be reported
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What is the most common personality disorder associated with Factitious Disorder?
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Borderline Personality Disorder
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What is the differential diagnosis of Factitious Disorder?
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1) Malingering
2) Actual General Medical Conditions 3) Somatoform Disorders |
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How can factitious disorder be differentiated from other somatoform disorders?
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Signs and symptoms are consciously produced by the patient
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How can Factitious Disorder be differentiated from Malingering?
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Signs and symptoms are consciously produced to assume the sick role, not to obtain external incentives
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When is the onset of Factitious Disorder?
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Adulthood, often following a hospitalization or health care experience
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How can the course of Factitious Disorder be characterized?
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Chronic, often switching between health care systems separated by geography
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How does a patient with Factitious Disorder respond to confrontation about the possibility that they are simulating illness?
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Patients are extremely resistant when confronted and may express anger and denial even in the face of overwhelming evidence that their signs and symptoms are intentionally produced. Often these patients will leave the health care setting by signing out AMA or eloping from the emergency room.
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How can further iatrogenic complications be avoided in patients with Factitious Disorder?
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Explicit documentation and communication between health care providers as to the false nature of illness
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How should Factitious Disorder be managed?
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Evaluation and appropriate treatment of other comorbid conditions, psychotherapy, and confrontation in appropriate patients once rapport has been established in the doctor-patient relationship.
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What is Malingering?
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Purposeful creation of signs and symptoms of illness in order to gain external incentives such as money, medications, successful litigation, or excuse from responsibilities.
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Is Malingering a mental illness?
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No. Malingering is listed in the DSM-IV as "Other Conditions That May Be a Focus of Clinical Attention"
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What gender presents with Malingering more frequently?
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Male
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In what 4 circumstances should malingering be suspected?
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1) Litigation is involved
2) Clinical presentation is out of proportion to physical examination or testing 3) Patients exhibit difficulty in adhering to a medical regimen or participating in diagnostic testing 4) Underlying antisocial personality disorder |
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How can the onset of Malingering be characterized?
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Onset is directly related to the availability of environmental incentives
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What are the 2 essential components of Malingering?
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1) Signs and symptoms of illness are consciously created by the patient in the absence of true pathology
2) Ultimate goal of such behavior is to obtain some external incentive |
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How can Malingering behavior be terminated?
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Remove the external incentive
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What concepts are important in dealing with Malingering?
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- Maintaining confidentiality
- Using a nonjudgmental approach to confronting the patient - Demonstrating willingness to explore possible underlying psychosocial issues that may be contributing to Malingering through psychotherapy |
