1. Somatoform & Factitious Disorders

2. Factitious Disorder Physical or psychological Sx that are intentionally feigned for the purpose of fulfilling an intrapsychic need to adopt a sick role. Presents history very dramatically with vague & inconsistent details When confronted with evidence of inconsistencies, will deny allegations and often avoid further evaluation These individuals have frequently had numerous surgeries or other invasive medical procedures.

3. Factitious Disorder l Primarily physical l Primarily psychological

4. Malingering

5. Somatoform Disorders l Presentation of physical symptoms that suggest a physical disorder –Symptoms not fully explained by: l The medical condition l Substance use l Another mental disorder l Must judge the onset, severity, and duration of symptoms for proper diagnosis

6. Somatoform Disorders l Somatization disorder l Conversion disorder l Hypochondriasis l Body dysmorphic disorder l Pain disorder l Two other residual categories

7. Somatization Disorder l History of many physical complaints beginning before 30. Very chronic course and result in tx being sought or significant role impairment. l During a episode, the following must occur –4 pain sx –2 GI sx –one sexual sx –and 1 psuedoneurological sx

8. Somatization continued l Not due to GMC or l When related to GMC, the resulting social or occupational impairment are ins excess of what would be expected from physical exam, history, or labs

9. Somatization D/O- Epidemiology l Rare in men; much more common in psychiatric patients l More among low SES groups and EMs l 20% of 1st degree female relatives of these pts. will have a somatization d/o. l Differentials

10. First Aid for Somatizers l Recent study found that a brief psychiatric consultation followed by a letter to the doctor greatly reduced cost and somaticizing tendencies. l Schedule brief appointments and Phx. Exams every 4 to 6 weeks; only at set times and NOT on demand; avoid lab tests, surgery and hospitalization unless absolutely necessary and avoid suggesting that the problems are all in his/her mind l Charges fell 25 to 33% as did subjective pain Smith, Rost & Kashner (1995). Archives of General Psychiatry, 52.

11. Case Example l 44 year-old African American pt. With reported history of recent TBI in which he was kicked in the back of the head and everything went black. l NP Testing: MMSE=13, poor memory and exec. functioning. Language intact l Presentation and follow-up

12. Conversion Disorder l Usually a single motor or neurological symptom with symbolic meaning that affects voluntary motor or sensory function. l Frequently primary (protects) or secondary gain (gratifies). l Sudden onset of symptoms (usually a temporal relationship)

13. Conversion D/O Etiology & Prevalence l Equal in men and women l More common in lower SES groups and in subcultures that consider these symptoms as being expectable l Often medical impossibility that confirms their conceptualization of CNS function

14. Conversion D/O Treatment l Important to rule out GMC such as Multiple Sclerosis and Lupus l Remove from situation, reinforce alternative coping strategies and occasionally hypnosis

15. Pain Disorder-Presentation l Symptoms are usually initiated by an acute stressor, erupt suddenly, intensify over the next several days or weeks and subside when the acute stressor is gone. l Patients frequently have secondary gain (“doctor shop”) and have symptoms that worsen under stress.

16. Pain D/O Epidemiology & Prevalence l Initially afflict women more, but sex differences fall out after major depression is eliminated. l More common in relative with pain problems and patients with physically demanding jobs.

17. Pain D/O Treatment l Acute management- giving insufficient narcotics leads to moderate and severe distress in 3/4 of the patients. Drs. fear addiction. Don’t give narcotics PRN!! l Chronic management- Cognitive behavioral therapy, pharmacotherapy and “team” tx.

18. Hypochondriac l Overwhelming, persistent preoccupation with physical sxs. based on unrealistically ominous interpretation of physical signs or sx l Ex. Felix Unger l Affects both sexes equally; begins 20-30 l La belle indifference

19. Body Dysmorphic Disorder l Focus on obsession with perceived fault in physical appearance or imagined image l Greater in women (3:1) l Mood disorders usually come AFTER not before the sx of BDD l Treatment –Behavior therapy and serotonergic antidepressants (OCD variant?)