1. Somatoform & Factitious Disorders
(Thanks to:
Drew Bradlyn, Ph.D.)

2. Somatoform Disorders Key Feature: Types Somatization Disorder
Conversion Disorder
Hypochondriasis
Somatoform Pain Disorder
Body Dysmorphic Syndrome
Undifferentiated Somatoform Disorder

3. Quick but irrelevant
Body Dysmorphic Disorder
Pain Disorder

4. Somatization Disorder: Diagnostic 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

5. Somatization Disorder: Associated Features
Colorful, exaggerated terms
Inconsistent historians
Depressed mood and anxiety symptoms
Chronic, rarely remits completely
Lifetime prevalence: 0.2% - 2% F
< 0.2% among men
REMEMBER--somatizing patients can also develop medical conditions!

6. Hypochondriasis: Diagnostic 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
Brain tumor

7. Hypochondriasis: Associated 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

8. Conversion Disorder: Diagnostic 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

9. Conversion Disorder: Associated Features
In % ->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
Outpatient mental health: 1 - 3%
“la belle indifference”
Histrionic
Figure of identity

10. More on Somatoform 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

11. 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)
GAINS OF ILLNESS:
-primary gain: keeping internal conflicts outside awareness
-secondary gains: excused from obligations, financial incentive
SOCIAL ISOLATION: low social support use have higher medical utilization
COMMUNICATION: bodily symptoms represent a cry for help
PHYSIOLOGIC: psych problems may have phys sym (PANIC)
SYMPTOM TRT: leads to reinforcing somatic view of illness (PANIC treated w/beta blocker/pt believes cardiac disease

12. Differential

13. Differential Things that affect: Concrete findings
Perception of Illness
Presentation of Illness

14. “Concrete”
Diseases that don’t follow the rules

15. Perception Psych diseases: Depression Anxiety Psychosis
Other, weirder stuff

16. Presentation
Malingering
Factitious Disorder
More normal things

17. Factitious Disorder
Key Feature: Sx’s Intentionally produced to assume sick role
Types
Factitious Disorder
Factitious Disorder by Proxy

18. Factitious Disorder: Associated Features
M > F
Hospital/healthcare workers
External incentives absent
Distinguished from somatoform… Distinguished from malingering…

19. 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.
What’s going on!

20. Review Question
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?

21. 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 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.