Download DSM-IV

Somatoform &
Factitious Disorders
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.
Factitious Disorder

Primarily physical

Primarily psychological
Malingering
Somatoform Disorders

Presentation of physical symptoms that
suggest a physical disorder
– Symptoms not fully explained by:
The medical condition
 Substance use
 Another mental disorder


Must judge the onset, severity, and duration
of symptoms for proper diagnosis
Somatoform Disorders
Somatization disorder
 Conversion disorder
 Hypochondriasis
 Body dysmorphic disorder
 Pain disorder
 Two other residual categories

Somatization Disorder


History of many physical complaints beginning
before 30. Very chronic course and result in tx
being sought or significant role impairment.
During a episode, the following must occur
– 4 pain sx
– 2 GI sx
– one sexual sx
– and 1 psuedoneurological sx
Somatization continued
Not due to GMC or
 When related to GMC, the resulting social
or occupational impairment are ins excess
of what would be expected from physical
exam, history, or labs

Somatization D/OEpidemiology
Rare in men; much more common in
psychiatric patients
 More among low SES groups and EMs
 20% of 1st degree female relatives of these
pts. will have a somatization d/o.
 Differentials

First Aid for Somatizers



Recent study found that a brief psychiatric
consultation followed by a letter to the doctor
greatly reduced cost and somaticizing tendencies.
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
Charges fell 25 to 33% as did subjective pain
Smith, Rost & Kashner (1995). Archives of General Psychiatry, 52.
Case Example
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.
 NP Testing: MMSE=13, poor memory and
exec. functioning. Language intact
 Presentation and follow-up

Conversion Disorder
Usually a single motor or neurological
symptom with symbolic meaning that
affects voluntary motor or sensory function.
 Frequently primary (protects) or secondary
gain (gratifies).
 Sudden onset of symptoms (usually a
temporal relationship)

Conversion D/O
Etiology & Prevalence
Equal in men and women
 More common in lower SES groups and in
subcultures that consider these symptoms as
being expectable
 Often medical impossibility that confirms
their conceptualization of CNS function

Conversion D/O Treatment
Important to rule out GMC such as
Multiple Sclerosis and Lupus
 Remove from situation, reinforce alternative
coping strategies and occasionally hypnosis

Pain Disorder-Presentation
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.
 Patients frequently have secondary gain
(“doctor shop”) and have symptoms that
worsen under stress.

Pain D/O Epidemiology
& Prevalence
Initially afflict women more, but sex
differences fall out after major depression is
eliminated.
 More common in relative with pain
problems and patients with physically
demanding jobs.

Pain D/O Treatment
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!!
 Chronic management- Cognitive behavioral
therapy, pharmacotherapy and “team”
tx.

Hypochondriac
Overwhelming, persistent preoccupation
with physical sxs. based on unrealistically
ominous interpretation of physical signs or
sx
 Ex. Felix Unger
 Affects both sexes equally; begins 20-30
 La belle indifference

Body Dysmorphic Disorder
Focus on obsession with perceived fault in
physical appearance or imagined image
 Greater in women (3:1)
 Mood disorders usually come AFTER not
before the sx of BDD
 Treatment

– Behavior therapy and serotonergic
antidepressants (OCD variant?)