Download 198 - Conversion Disorder, Psychosomatic Illness, and Malingering

198 Conversion Disorder,
Psychosomatic Illness, and Malingering
Glen E. Michael and J. Stephen Huff
KEY POINTS
• Somatization disorder, conversion disorder, and
hypochondriasis are psychologic reactions to stressful
circumstances that are neither intentional nor planned.
• Malingering and factitious disorders involve deliberate
actions of deceit of which the patient is aware.
• Somatoform conditions feature complaints and
symptoms that cannot be attributed to medical illness.
• Emergency department evaluation of patients with
suspected somatoform disorders should focus on the
search for a medical cause of the reported symptoms
and exclusion of life-threatening illness.
• Identification and appropriate referral of patients with
somatoform illness are secondary objectives of the
emergency department encounter.
• As with other psychiatric and medical diagnoses,
thorough documentation is required when somatization
is suspected.
EPIDEMIOLOGY
Somatoform conditions include the following diagnoses:
somatization disorder, conversion disorder, somatoform pain
disorder, hypochondriasis, body dysmorphic disorder, and
undifferentiated somatoform illness. The boundaries between
these disorders can be subtle, and it has recently been proposed that four of these conditions—somatization disorder,
somatoform pain disorder, hypochondriasis, and undifferentiated somatoform illness—should be reclassified under a
single common rubric called complex somatic symptom disorder (CSSD).1 Further classification of somatoform disorders
is continually evolving as research better defines their distinctive characteristics.1-3
The reported prevalence of somatoform conditions ranges
from 50% to 65% in ambulatory settings.4,5 When definitions
are narrowed to include only patients meeting strict diagnostic
criteria for somatization disorder, the lifetime prevalence
drops to less than 3%.6 Accurate classification is difficult
Acknowledgment and thanks to Dr. Marshall for his work on the first edition.
1648
because some patients exhibit somatoform symptoms in the
presence of demonstrable medical illness.
True somatization disorder (or Briquet syndrome, after
Paul Briquet, who first described the illness in 1859) is typically manifested before 30 years of age and is far more
common in women than in men. Although many patients
somatize, somatization disorder is ultimately diagnosed
in few.
DEFINITIONS
Somatization disorder is characterized by the presence of multiple chronic distressing somatic symptoms that are not medically explained. Patients with this condition tend to be highly
anxious about their symptoms, even in the face of evidence
that their condition is not medically serious. In the draft of the
upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-V), this condition has been renamed CSSD.1
Hypochondriasis is preoccupation with or excessive fear of
illness despite negative testing and reassurance from a health
care professional. Hypochondriasis is more common than
somatization disorder and has a prevalence of 4% to 9% in
general medical practice.7 It peaks in men in the fourth decade
and in women in the fifth, with no significant predilection by
gender. Hypochondriasis is increasingly being described in
geriatric populations.8 It has been renamed the “predominant
health anxiety” subtype of CSSD in the proposed draft of
DSM-V.1
Somatoform pain disorder, an important and particularly
challenging somatoform illness, is characterized by somatoform symptoms that are manifested predominantly as pain. In
the proposed draft of DSM-V, this condition is reclassified as
the “predominant pain” subtype of CSSD.1
Conversion disorder is a condition in which patients
complain of sensory or motor symptoms as a manifestation
of stress or unconscious conflict that cannot be attributed to
a pathophysiologic process. Conversion disorder is more
common in women and members of lower socioeconomic
groups. Its onset typically begins in adolescence, and it
follows a discontinuous course. Conversion disorder has also
been observed in military, mass casualty, and industrial accident settings without a female preponderance of the disorder.9
Estimates of prevalence vary considerably as a result of inconsistent classifications and definitions of the disorder.
CHAPTER 198
Conversion Disorder, Psychosomatic Illness, and Malingering
Body dysmorphic disorder is characterized by a preoccupation with an imagined defect in physical appearance. Although
it is currently classified under somatoform disorders, body
dysmorphic disorder more closely resembles obsessivecompulsive disorder and as a result may be moved to the
anxiety disorders section of the DSM-V.1 This disorder is
commonly encountered by primary care providers, plastic surgeons, and the body enhancement industry.
Factitious disorders, including malingering, feature deliberate manufacturing of symptoms or illness. The combined
prevalence of all factitious disorders ranges from 1% to 5%,
again with a female preponderance. The term Munchausen
syndrome (after the famous 18th-century raconteur Baron von
Munchausen) is reserved for chronic or “career” medical
imposters, and it represents the extreme form of the disorder.
However, cases of Munchausen syndrome tend to involve
male patients.10
Malingering and symptom exaggeration are probably
underreported. In one study, “39% of mild head injury, 35%
of fibromyalgia/chronic fatigue, 31% of chronic pain, 27% of
neurotoxic, and 22% of electrical injury claims resulted in
diagnostic impressions of probable malingering.”11 Malingering is most often exhibited by patients who are either trying
to avoid an unpleasant circumstance, such as military duty or
a prison term, or attempting to secure some form of compensation, such as occupational health or personal injury plaintiff
claims. Malingering can result in criminal charges.12
Factitious disorder by proxy or Munchausen syndrome by
proxy deserves special mention because it may represent a
form of child abuse. It is typically defined as the intentional
production or feigning of physical or psychiatric illness in a
child by the child’s guardian, although it has also been reported
in caregivers of geriatric patients. Factitious disorder by proxy
can be active (symptom producing) or passive (neglect).
Munchausen syndrome by proxy is rare and occurs in roughly
2.8 per 100,000 children younger than 1 year and 0.5 per
100,000 children younger than 16 years.13 As with the other
factitious illnesses, the deceptive nature of the disorder makes
it extremely difficult to detect and study.
PATHOPHYSIOLOGY
Somatoform illnesses represent emotional stress experienced
as physical symptoms. Both somatization and hypochondriasis are commonly associated with depression and anxiety, and
somatization is classified as a potential initial symptom of
depression.14 This strong association with depressive disorders has led to the practice of treating somatization with
antidepressant medications. Hypochondriasis and depression
coexist in roughly 40% of cases. Twenty percent of patients
with hypochondriasis have a diagnosis of panic disorder, and
10% have an obsessive-compulsive disorder.15 As the number
of reported physical symptoms rises in patients with somatoform illness, the likelihood of an underlying psychiatric disorder increases proportionately.16
A significant correlation does not appear to exist between
psychiatric illness and factitious disorder, unlike somatization
and hypochondriasis. Malingering is observed in individuals
with antisocial and psychopathic personalities, but the nature
of this association remains unclear.
PRESENTING SIGNS AND SYMPTOMS
CLASSIC FEATURES
Somatization is exhibited by patients who are chronically
and persistently “sick” with numerous vague complaints and
symptoms involving many organ systems; review of systems
is often globally “positive.” Patients’ symptoms are distressing
to them, and their suffering is authentic even if medically
inexplicable. Patients maintain a very strong conviction of
illness despite multiple negative diagnostic work-ups, hospital
admissions, specialist referrals, and surgical procedures. An
example of the breadth of symptoms associated with somatoform disorders can be seen in the diagnostic criteria listed in
Box 198.1.
Patients with hypochondriasis, like somatizers, are convinced that they are gravely ill. Although a somatizer focuses
on symptoms, a patient with hypochondriasis focuses on
disease states and invests great personal energy in seeking
multiple extensive reassurances from the health care system.
Patients with hypochondriasis are typified by health anxiety
leading to strong convictions of illness and fixation with the
body and its functions. Ominous implications are often attributed to mundane or insignificant findings, and symptoms are
exaggerated out of proportion to any actual organic illness.
Conversion disorder, in contrast to somatization disorder,
is the acute, often episodic onset of one symptom or sign
involving limited body parts or organ systems. Complaints are
generally sensory or motor in nature and often occur in
response to an identified stressor. Unlike malingering or factitious disorders, the malady is not consciously feigned or
deliberate. Examples of conversion disorder typically seen in
the ED include pseudoseizures, altered mental status, paralysis, and movement disorders.17 Other common conversion
symptoms are presented in Box 198.2.
BOX 198.1 Diagnostic and Statistical Manual of
Mental Disorders (Fourth Edition, Text Revision)
Criteria for Somatization Disorder
1. Pain in at least four distinct locations or circumstances
(e.g., headache, backache, chest pain, dysuria,
dyspareunia)
2. Two or more gastrointestinal symptoms (e.g., nausea,
vomiting, diarrhea, constipation, but not pain)
3. One or more sexual dysfunction symptoms (e.g., impotence, lack of libido, menorrhagia, but not pain)
4. One or more neurologic conversion symptoms (also see
Box 198.2) (e.g., paresthesia, paralysis, ataxia, blindness,
pseudoseizure)
Symptoms are not medically explainable or may represent
an exaggeration of symptoms attributable to an organic
illness.
Symptoms must not be deliberately produced.
Adapted from American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th ed, text rev. Washington, DC: American
Psychiatric Association; 2000.
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EMERGENCY PSYCHIATRIC DISORDERS
One of the more unusual conversion disorders is pseudocyesis, or “hysterical pregnancy,” which includes the physical
symptoms of pregnancy (even amenorrhea) in the absence of
a true gestation.
La belle indifférence, a seemingly incongruous disinterest
in one’s illness, is classically associated with conversion reactions. However, la belle indifférence may be seen with organic
disease states such as stroke. La belle indifférence should not
be used alone to differentiate between conversion and organic
disorders.18
Patients who malinger and those who have factitious disorder tend to limit themselves to exaggerations of symptoms
of a previously diagnosed illness or to symptoms that are
difficult to investigate and disprove; examples include pain
of any variety, psychiatric conditions such as suicidality, and
the pseudoneurologic symptoms of tingling, amnesia, and seizures. Less commonly, patients with factitious disorder inflict
injury or disease on themselves. Deliberate misuse of medications such as hypoglycemic agents has been described in
health care workers.10
Unlike the somatoform disorders, malingering and factitious behavior involve feigned illness. Even though they are
aware of their deception, patients with factitious disorder
(unlike malingerers) are helpless to control the behavior.19 To
illustrate the differences among somatoform disorder, factitious disorder, and malingering, one can use the example of
nonepileptic or pseudoseizures, which can be seen in each
condition. A patient with a somatoform disorder suffers a
nonvolitional convulsion in response to a psychologic stressor,
BOX 198.2 Common Conversion Symptoms
Anesthesia
Paresthesia
Paralysis
Ataxia
Syncope
Seizure
Coma
Vertigo, dizziness
Diplopia
Blindness
Deafness
Tremor
Globus hystericus
Dysphagia
a patient with factitious disorder has an uncontrollable compulsion to feign a nonepileptic convulsion to gain attention
and the sick role, and a patient who malingers feigns a convulsion as part of a ruse to achieve a specific end. What sets
malingering apart from factitious disorder is the patient’s
intentional pursuit of an identifiable, tangible goal or gain.20
VICTIMS OF INTIMATE PARTNER VIOLENCE
Among patients who tend to use emergency care frequently,
an important subgroup consists of victims of intimate partner
violence (see Chapter 93). Intimate partner violence results
in high levels of psychologic stress for the victim. Many of
these patients repeatedly seek care in the ED with somatoform
behavior.21 Physicians must screen for ongoing abuse when
new or recurrent physical symptoms cannot be attributed to a
medical condition. Just as with current abuse, patients with a
past history of physical, sexual, or psychologic abuse also
tend to use medical services more frequently.
DIFFERENTIAL DIAGNOSIS AND TESTING
In the emergency department (ED), the brevity of the clinical
encounter and a diagnostic focus on life threats make accurate
identification of patients with somatoform disorders difficult.
Even when demonstrable medical disease is present, symptoms and severity are modulated by the psychologic wellbeing of the patient. Even though it stands to reason that many
patients somatize to some degree, clearly a subset exists in
whom such behavior represents a disorder.
The goals when evaluating somatoform illness are identification of the condition and appropriate referral. In the ED,
life-threatening conditions on the differential diagnosis are
excluded first, other potentially serious medical illnesses are
excluded second, and somatoform causes are excluded last, if
at all.
Classic findings can make one suspect a somatoform
illness; however, such behavior is insufficient for psychiatric
diagnostic criteria. Synopses of the characteristics of somatoform disorders can be found in Table 198.1. It is useful
to categorize these illnesses as nondeliberate (somatization,
Table 198.1 Characteristics of Somatoform Disorders
DISORDER
HALLMARKS
Somatization
disorder
Multiple, chronic vague symptoms occurring in different organ systems
Many past medical evaluations
Associated psychiatric disorder
Conversion
disorder
Acute, episodic
Limited symptoms and body parts
Motor or sensory complaints predominant
Hypochondriasis
Health anxiety
Fixation on diagnoses and body functions
Factitious disorder
Compulsive urge to feign illness by report or deed
Malingering
Feigned illness for the purpose of avoiding something unpleasant or to gain some reward
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CHAPTER 198
Conversion Disorder, Psychosomatic Illness, and Malingering
conversion disorder, and hypochondriasis) and deliberate
(factitious disorders and malingering).
The symptoms experienced by a patient with a nondeliberate somatoform illness are perceived as very real. Diligent
history taking often uncovers telling patterns. Useful questions to consider include the following: Are these complaints
chronic? Do they correlate with identifiable stressors? Does
the patient hold a conviction of a particular illness or imminent death? Does the patient have a lifelong history of
“illness”? What has been done for this patient in previous
visits, by previous providers? What is new today? Obtaining
answers to these questions, along with a careful physical
examination, can help direct the emergency evaluation while
at the same time reassuring patients that they are being taken
seriously. Respect ultimately aids in disposition because these
patients are far more likely to comply with a plan when they
believe that a provider has their best interests at heart.
Concerns about making the diagnosis of a somatoform
illness should not preclude a thorough ED evaluation because
many medical conditions can be mistaken for somatization,
particularly when the findings are atypical. Box 198.3 provides examples of medical conditions that can mimic somatoform behavior.
As a general rule, patients with nondeliberate somatoform
illness acquiesce to invasive diagnostic testing, whereas those
with factitious disorders and malingerers are more reluctant.
The presence of two or more of the following features is
BOX 198.3 Medical Conditions That May Be
Mistaken for Somatization
Multiple sclerosis
Thyroid disorders
Guillain-Barré syndrome
Porphyria
Botulism
Myasthenia gravis
Parathyroid disorders
Insulin derangements
Uremia
Periodic paralysis
Lupus
Pituitary disorders
Addison disease
Wilson disease
Carbon monoxide exposure
Medication side effects
suggestive of malingering behavior: mention of a medicolegal
context of the visit, discrepancy between subjective and objective assessment of the degree of stress and disability, poor
compliance with evaluation and treatment, and antisocial personality disorder.19 Malingering is very difficult to prove, even
in the presence of high clinical suspicion and deliberate investigation, and surveillance of the patient is often required.22
Determination of malingering is usually the purview of specialists such as neuropsychologists.
Various maneuvers are purported to assist in identifying
factitious symptoms, as shown in Table 198.2. Waddell’s
“behavioral responses to examination,” as applied to a chief
complaint of back pain, are one example. Although the
Waddell signs provide a compelling method of detecting
feigned illness, the predictive value of such maneuvers is
generally poor and correlates with an unfavorable treatment
outcome.23
Tests for factitious paralysis have also been proposed but
are similarly nonspecific.24 The abductor test is one such test:
with true paresis, the unaffected leg abducts when the patient
attempts to abduct the affected leg against resistance. The
Hoover test involves placing the examiner’s hand under the
“weakened” lower extremity and asking the supine patient to
raise the unaffected leg; downward pressure with the affected
leg is considered positive for feigned paralysis. Prudent
caution is warranted in the interpretation of any diagnostic
maneuver that is infrequently performed.
TREATMENT
No specific treatment of nondeliberate somatoform illness
exists. Psychiatric comorbid conditions such as depression,
anxiety, and substance abuse should be addressed. Cognitive
behavioral therapy has shown promise in the minority of
patients willing to be referred.25,26
Whether to use medication to treat symptoms believed to
be somatoform in origin is as much an ethical question as a
medical one. This quandary often develops when considering
analgesics for chronic pain syndromes. In accordance with the
principles of beneficence and nonmaleficence, one may want
to spare a patient potential side effects and addiction; this is
Table 198.2 Physical Examination Maneuvers Purported to Differentiate Factitious from Organic Conditions
TEST
SYMPTOM
DESCRIPTION
RELIABILITY OF TEST
Hoover
Leg paresis
Cup the heel of the weakened leg with the examiner’s hand, and
have the patient raise the unaffected leg. The paresis is nonorganic
if downward pressure is exerted on the hand.
Poor
Abductor
Leg paresis
Instruct the patient to abduct the weakened leg against resistance. In
true paresis, the opposite leg should consensually abduct.
Poor
Arm drop
Arm paresis
Raise the paretic arm above the patient’s face and then release. If the
dropped arm misses the face, a nonorganic cause is suggested.
Poor
Midline
split
Sensory
loss
Test facial sensation. Sharp demarcation of sensory loss at the
midline suggests a nonorganic cause.
Poor
Adapted from Greer S, Chambliss L, Mackler L, et al. Clinical inquiries: what physical exam techniques are useful to detect malingering? J Fam Pract
2005;54:719-22.
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SECTION XIX
EMERGENCY PSYCHIATRIC DISORDERS
countered by the harm of leaving a patient in pain or consigning the patient to withdrawal if he or she is a chronic user of
analgesics.
The final common pathway of pain is the perception of
pain, and even imagined pain can be very real. Given that
emergency providers do not primarily manage somatoform
illness, it is not unreasonable to provide short-term “bridging”
prescriptions on a case-by-case basis to patients with appropriate follow-up arrangements. Patients who seek care only to
acquire narcotics are not considered to be suffering from
somatoform illness; rather, they may have substance abuse,
addiction, or illegal market motivations.
intervention. Discharge instructions should ideally include
times, dates, and names of follow-up visits; doses of medications; and specific return criteria.
The final discharge diagnosis should reflect the chief complaint (e.g., “leg pain”) rather than the suspected somatoform
behavior. This is particularly true of feigned illness because
these diagnoses may have criminal implications. Exceptions
to this rule are suspected intimate partner violence or
Munchausen syndrome by proxy, which deserve special consideration. In both these instances, a high index of suspicion
for the condition is appropriate, and interventions such as
reporting or activating protective services may be required.
FOLLOW-UP AND NEXT STEPS IN CARE
SUGGESTED READINGS
It is not generally recommended that a patient with a somatoform illness be confronted. Instead, the patient should be
reassured that the symptoms do not represent an imminent
threat. Even in cases of malingering, neuropsychologists
rarely confront patients; most use descriptive terminology
rather than the diagnosis “malingering.”27
Good charting practices are critical when somatization is
suspected. The history of the present illness and review of
systems should include liberal use of patient quotes to convey
the character of the visit to subsequent providers. Findings on
physical examination also need to be documented carefully
because they may be the reason to pursue or defer diagnostic
1652
Dula D, DeNaples L. Emergency department presentation of patients with conversion
disorder. Acad Emerg Med 1995;2:120-3.
Greer S, Chambliss L, Mackler L, et al. Clinical inquiries: what physical exam
techniques are useful to detect malingering? J Fam Pract 2005;54:719-22.
Mendelson G, Mendelson D. Malingering pain in the medicolegal context. Clin J Pain
2004;20:423-32.
Stone J, Smyth R, Carson A, et al. La belle indifférence in conversion symptoms and
hysteria: systematic review. Br J Psychiatry 2006;188:204-9.
REFERENCES
References can be found
www.expertconsult.com.
on
Expert
Consult
@
CHAPTER 198
Conversion Disorder, Psychosomatic Illness, and Malingering
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