Somatic Symptom (Somatoform) Disorders, Factitious Disorders, and Malingering



Somatic Symptom (Somatoform) Disorders, Factitious Disorders, and Malingering





At least 30% of the physical complaints of primary care patients cannot be explained by organic illness (Kroenke et al., 1994; Kroenke, 2007). Although understanding the social and psychiatric influences on these complaints is essential for appropriate management, patients with unexplained symptoms present a diagnostic and treatment challenge for even the most empathic and dedicated doctor (Hartz et al., 2000).

Patients with unexplained physical symptoms fall into two general categories (Fig. 16-1). In the first category, symptom formation is unconscious. These patients come to the doctor believing that they are medically ill. This category includes patients with somatic symptom disorders, a group of emotional disorders characterized by physical symptoms that suggest organic pathology (see later text); and patients with depressive illnesses, because “masked depression” (see Chapter 13) commonly presents with physical symptoms. In the second general category, symptom formation is conscious. Individuals with these conditions, which include factitious disorders and malingering, feign mental or physical illness or actually induce physical illness in themselves or in close relatives. In factitious disorders, the symptoms are feigned for unconscious psychological reasons (e.g., to gain attention and care from medical personnel). In malingering, the symptoms are invented for conscious, tangible gain, such as money in a lawsuit or release from legal, work, or school responsibilities.






FIGURE 16-1. The differential diagnosis of a patient with medically unexplained physical symptoms.


• SOMATIC SYMPTOM (SOMATOFORM) DISORDERS

Persons who have somatic symptom disorders are not lying; they truly believe that they have physical problems (Cloninger & Dokucu, 2008). They tend to seek medical attention, typically visiting many different doctors searching for help (doctor shopping). Their symptoms commonly lead to impairment in social or occupational functioning. Approximately 50% of patients with a somatic symptom disorder also have another mental symptom, most commonly depression or anxiety (Simon et al., 1999; Green et al., 2000; Otto et al., 2001).


Classification

The major DSM-5 classifications of somatic symptom and related disorders are




  • somatic symptom disorder


  • functional neurological symptom disorder (conversion disorder)


  • illness anxiety disorder (hypochondriasis)

Body dysmorphic disorder is no longer in this category but is discussed in this Chapter. Selected DSM-5 criteria for and specific examples of patients with each disorder are listed in Table 16-1. Unspecified somatic symptom and related disorder is diagnosed when the unexplained symptoms, such as fatigue, loss of appetite, and gastrointestinal (GI) or genitourinary complaints, do not fit the diagnostic criteria for any of the other somatic symptom and related disorders.








table 16.1 SOMATIC SYMPTOM AND RELATED DISORDERS

































SELECTED DIAGNOSTIC CRITERIA

PATIENT EXAMPLE


Somatic symptom disorder




  • Somatic symptoms that are distressing or disruptive to daily life persisting for more than 6 months



  • Specifiers include with predominant pain or persistence



  • Severity is classified as mild, moderate or severe

A 39-year-old woman has a 20-year history of somatic complaints such as headache (pain symptom), nausea (GI symptom), menstrual irregularities (sexual symptom), and temporary loss of sensation in her hands (pseudoneurological symptoms). She tells the doctor that she is always sick but that her previous doctors never seemed to identify the problem and were unable to help her.


Functional neurological symptom disorder (conversion disorder)




  • One or more symptoms affecting voluntary motor or sensory function and suggesting a neurologic etiology

A 28-year-old woman experiences a sudden loss of vision but appears unconcerned. Medical tests are essentially normal. The patient reports that, just before the onset of her blindness, she saw her child dart out into the street.


Illness anxiety disorder (hypochondriasis)




  • Preoccupation with fear or idea of having a serious disease but somatic symptoms are absent or mild



  • Fear persists despite negative medical findings and physician’s reassurance



  • There are excessive health-related behaviors or maladaptive avoidance of medical care

A 41-year-old man reports that he has seen many doctors for his persistent illnesses but is frustrated because they have ultimately referred him to mental health clinicians. He now fears that he has stomach cancer because his stomach makes noises after he eats. Medical tests are negative and his doctor has repeatedly told him that nothing is wrong with him.


Body dysmorphic disorder




  • Preoccupation with an imagined problem with one’s appearance or an insignificant physical abnormality



  • The preoccupation is not accounted for by anorexia nervosa (see Chapter 17)

A 28-year-old woman seeks rhinoplasty for her “huge” nose. She rarely goes out in the daytime because she believes that this characteristic makes her look “like a hag.” On physical examination, her nose appears completely normal.


Somatic symptom disorder with predominant pain (pain disorder)




  • Pain severe enough to seek medical attention



  • Psychological factors are involved in the onset or other aspect of the pain

A 40-year-old man who suffered a minor knee injury while playing foot ball 11 months ago continues to complain of severe knee pain although there is no evidence of pathology.


(Adapted with permission from Fadem B, Simring S. High-Yield Psychiatry. Baltimore: Lippincott Williams & Wilkins; 2003.)



Etiology

Unconscious as well as social factors are involved in the etiology of the somatic symptom disorders. Although the patient is not consciously aware of it, primary or secondary gain may result from the symptoms. Primary gain involves using the defense mechanism of somatization (see Chapter 8) to unconsciously express an unacceptable emotion as a physical symptom to avoid dealing with the
emotion. Secondary gain means that the symptom, once established, serves a useful purpose, such as getting attention from others or avoiding responsibility (e.g., “I cannot take care of myself, so you will have to take care of me”).

Genetic and familial factors have also been associated with the somatic symptom disorders. Some of these disorders tend to run in families and have higher concordance rates in monozygotic than in dizygotic twins. A family history of mood disorder, obsessive-compulsive disorder, antisocial personality disorder and alcoholism is more common in patients with somatic symptom disorders.

The somatic symptom disorders tend to start in early adulthood and have chronic symptoms that worsen during times of stress and that improve when life conditions are more favorable. Most of these disorders are more common in women, although hypochondriasis occurs equally in men and women.


Somatic symptom disorder

Somatic symptom disorder is a specific disorder in this group. It is characterized by a history of one or more physical symptoms, including pain and GI, sexual, and neurological symptoms, for which no cause or inadequate medical cause is found, and that disrupt daily life. The symptoms tend to be chronic and total remission is rare. Because the physical symptoms of somatic symptom disorder vary by culture, social factors and learning may be involved in its etiology.


Hypochondriasis and illness anxiety disorder

Because the name may be seen as pejorative, hypochondriasis has been eliminated as a disorder in the DSM-5. Patients with some symptoms of hypochondriasis may now be diagnosed with illness anxiety disorder. In contrast to somatic symptom disorder, in which the symptoms of illness predominate, fear of having a serious illness although no severe symptoms of illness are present is the focus of illness anxiety disorder. Because of the persistent and repetitive nature of these concerns, illness anxiety disorder may have a similar etiology to other disorders characterized by recurrent unwanted thoughts and behaviors, such as OCD (see Chapter 15) and impulse control disorders (e.g., trichotillomania [compulsive hair pulling]) (see Chapter 22). As evidence for an etiologic similarity, selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), that improve symptoms in patients with OCD and impulse control disorders also improve symptoms in some nondepressed illness anxiety disorder patients (O’Malley et al., 1999). A hallmark of illness anxiety disorder is that patients are not reassured by doctors or by negative laboratory tests and, instead, continue to worry that they have a serious illness and to go “doctor shopping.”


Functional neurological symptom (conversion) disorder

Functional neurological symptom disorder involves the sudden, dramatic loss or change of neurological function, either motor (e.g., paralysis) or sensory (e.g., hearing or vision). In describing this disorder, Freud noted that the symptoms had obvious and symbolic significance associated with a particular stressful life event. For example, a woman getting married in the near future finds that she is suddenly unable to move her legs. Perhaps because such symptoms decrease the individual’s anxiety about the life stressor that provokes them, patients with this disorder typically appear relatively unworried about their serious symptoms, a phenomenon known as la belle indifference.

The most common motor symptoms seen in this disorder include paralysis that shifts to different areas of the body, seizures that do not have an identifiable neurological basis (pseudoseizures), and globus hystericus (i.e., lump in the throat). The most common sensory presentations are paresthesias (abnormal sensations), anesthesias (loss of sensation often inconsistent with anatomic innervation), and visual problems (e.g., blindness or tunnel vision). Although evoked potentials and other measures of neurological function (see Chapter 6) are typically normal in patients with this disorder, these tests have low sensitivity and may be normal also in patients with “real” neurological illnesses.

Functional neurological symptom disorder is more common in psychiatrically unsophisticated patients, such as adolescents, young adults, and people from rural areas. It is often comorbid with histrionic personality disorder (see Chapter 24) and depression. Symptoms are commonly self-limited and remission usually takes place in less than 1 month. While the reasons are not clear, hypnosis or drug-assisted interviewing (see Chapter 6) is often quickly followed by remission of symptoms.

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Jun 16, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Somatic Symptom (Somatoform) Disorders, Factitious Disorders, and Malingering

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