Psychosomatic Disorders & Malingering

Factitious Disorder Imposed on self vs by Proxy

Imposed on the Self -Falsification of physical/psychological sx or induction of injury or disease -Patient presents as ill, impaired, injured -Behavior persists despite no known external reward -No other disorder exists to better explain sx In by proxy the victim likely receives an abuse dx

Malingering Core Features

Should be considered if: -Medicolegal context (i.e., litigation in progress) -Onset of illness coincides with a large financial incentive, such as a new disability policy or lawsuit -Significant discrepancy between subjective complaints versus objective data -Decreased cooperation during evaluations and/or treatment adherence -Antisocial personality disorder Examples of malingering: -Attempting to raise one's temperature -Adulterating a urine sample Considerations for assessment: -Performance validity measures -Symptom validity measures

Illness Anxiety Disorder

Duration at least 6 months (but type of dz feared may change) Care seeking type Care avoidance type -Sxs do not follow typical pattern -Reassurance initially fails -Frequent visits to doc Antianxiety treatment may reduce distress

Somatic Symptom Disorders

-Experiencing significant physical symptoms for which there is no apparent organic cause --As a result of psychological factors -Hard to detect or diagnose a psychological disorder for individuals with a real physical disorder --Must identify clear psychogenic causes --Must determine that symptoms are physiologically impossible ---False pregnancy, "illness" on exposure to disagreeable stimuli (e.g. math)

Somatic Symptom Disorder (aka Hypochondriasis)

-Persons augment and amplify their somatic sensations -Low threshold for any physical discomfort -Preoccupied with the false belief they have a serious illness based on misinterpretation of bodily sx --Convictions will persist despite negative labs/diagnostics --No medical findings to explain their symptoms -Can occur with depressive and anxiety disorders

Conversion Disorder Treatment

-Spontaneous resolution usually within 2 wks esp if stressor addressed -Referral for psychotherapy if stressors and /or symptoms persist -Communication with patient and family crucial and must be done carefully -Not medication responsive

Somatic Symptom Disorder Tx

-Treatments largely ineffective --unless co-morbid depression, anxiety disorder, etc. -Psychotherapy can be beneficial --Maybe in a group therapy component to reduce anxiety and have social support --CBT, if they will comply (but these pts. Often don't think they have a problem) -Best treatment is reassurance, not over evaluating, "watchful waiting" and continued availability -Protect the patient from unnecessary invasive and costly procedures -Regular scheduled visits prevent frequent phone calls, and normal PE findings -Don't try to convince the patient that it is psychological at the beginning

How is Somatic Symptom Disorder differentiated from Illness Anxiety Disorder?

-With Illness Anxiety, usually few to NO somatic complaints -Usually preoccupied with fear of having some disease vs physical complaints

Somatic Symptom Disorder specifiers

-With predominant pain: Replaces pain disorder -Persistent: lasting longer than 6 months -Severity --Mild: 1 B criteria --Moderate: > 2 B criteria --Severe: 2 > B criteria plus multiple somatic complaints (or one very severe symptom)

Two good complaints used by those who are Malingering

Abdominal pain, back pain

Conversion Disorder (Functional Neurological Symptom Disorder)

Illness of sx or deficits that affect voluntary motor or sensory functioning that arises from psychological origin -Physiologically normal -An unconscious process -stressful event may trigger -normal neuro exam -impaired but not distressed -Usually begins in early adulthood, rare after 35 y/o -Most common co-morbidities of depressive and anxiety disorders -May also see among histrionic personalities

_______ is a type of Factitious Disorder

Munchausen's Syndrome

How do you treat malingering?

NOT treatable -Avoid acquiescing to patient's persistent demands -Practice defensive medicine when suspecting malingering -GREAT DOCUMENTATION, SECOND OPINIONS -Confronting the malingerer is controversial but advised --Prevents repeat activity

Psychological Factors Affecting Other Medical Conditions

i.e. Anxiety influencing asthma (moderate), exerting oneself too much with degenerative arthritis of knees, ignoring heart attack symptoms (extreme). Tx: -Referral for clinical health psychology -Concurrent treatment of mood, anxiety -Empathetic reassurance

What is Factitious Disorder

patient consciously creates, simulates, induces, or aggravates physical and or psychological symptoms in order to assume "sick role" and to get medical attention regardless if they are truly ill Motivation: To receive medical care and partake in the medical system -May have suffered childhood trauma or deprivation -Form of repititional compulsion --Repeat the basic conflict of seeking and needing attention and love