SOMATOFORM DISORDER FACTITIOUS DISORDER - PowerPoint Presentation

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SOMATOFORM DISORDERFACTITIOUS DISORDERMALINGERING

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SOMATOFORM DISODERAre illness characterized by the presentation of physical symptoms without no medical explanations. The symptoms are severe enough to interfere with patient ability to function in social or occupational activities

Slide3

Patients

with

somatoform

disorders

present

with

enduring

physical

symptoms

without

an

identificable

organic

cause,

which

causes

significant

distress

or

impairment

in social,

occupational

,

or

other

área of

functioning

.

Although

the

symptoms

expressed

in

these

disorders

result

in

primary

and

secondary

gains

,

these

patients

truly

believe

that

their

symptoms

are

due

to medical problema.

They

are

not

consciously

feigning

symptoms

.

Mallingering

,

on

the

other

hand

,

is

when

one

consciously

feigns

symptoms

in

order

to

get

somthing

(

eg

,

money

)

Slide4

Primary

gain

:

Symptoms

as

an

unconcious

defense

against

unacceptableinternal

conflicts

(

self-justification

for

various

acions

or

lack

of

actions

)

Secondary

gain

:

Symptoms

that

provide

unconcious

EXTERNAL

benefits

(

increase

attention

from

others

,

decrease

responsabilities

,

avoidance

of

the

law

,

etc

)

Remark

: In

Mallingering

the

symptoms

are

consciously

feigned

.

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Review of distinguishing features.-

Somatoform

disorders

.-

PatientS

BELIEVE

they

are

ill

and do

not

intentionally

produce

or

feign

symptoms

.

Factitious

disorders

.-

Patient

intentionaly

produce

symptoms

of real

illness

because

of

desire

to asume

the

sick

role, no

for

external

rewards

.

Malingering

:

Patient

intentionally

produce

or

feign

symptoms

for

external

rewards

.

Slide6

Somatoform

disorders

are

generally

more

common

in

women

.

Half

of

patients

have

comorbid

mental

disorders

,

especially

anxiety

disorders

and

major

depression

.

Slide7

ICD-10 CLASSIFICATION

CODE

CATEGORY

F45.0

SOMATIZATION DISORDER

F45.1

UNDIFFERENTIAL SOMATOFORM

DISORDER

F44.

COVERSION(DISSOCIATIVE)

F45.4

PERSISTENT SOMATOFORM PAIN DISORDER

F45.2

HYPOCHONDRIACAL

DISORDER

F45.3

SOMATOFORM AUTONOMIC

DYSFUNTION

F45.8

OTHER SOMATOFORM DISORDER

F45.9

SOMATOFORM DISORDER UNSPECIED

F48.0

NEURASTHENIA(IN

OTHER NEOROTIC DISORDERS CATEGORY)

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DSM-V Classification

SOMATOFROM AND FACTITIOUS DISORDERS.-

Somatoform

disorders

.-

-------

Somatization

disorder

-------Conversión

disorder

-------

Hypochondriasis

-------

Body

d

ysmorphic

d

isorder

-------

Pain

disorder

(

Undifferentiated

and

not

otherwise

specified

)

Factitious

disorder

Malingering

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Somatization disorders

Patient

with

somatization

disorder

present

with

multiple

,

often

nonspecific

physical

symptoms

involving

many

ogan

systems

.

They

seek

treatment

from

many

doctors

,

often

resulting

in

extensive

lab

work

,

diagnostic

procedures

,

hospitalizations

, and /

or

surgeries

.

Incidence

in

females

up to 20 times

that

of males

Course

usually

chronic

and

debilitating

.

Symptoms

may

periodically

improve

and

then

worsen

under

stress

Patient

will

likely

resist

referral

to a

menthal

health

professional

.

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Somatization disorderSomatization disorder is characterized by the following clinical features:Multiple somatic symptoms in absence of any physical disorder.

The symptoms are recurrent and chronic(at least 2 years duration is needed for diagnosis.

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Diagnostic criteria(DSMIV- TR)A. History of physical symptoms:Beginning before 30years

Occurring over several years

Resulting in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

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CONTD….B. must meet each of the following criteria during the course of the disorder:

4 pain sign: a history of pain related at least 4 different sites(e.g. head, abdomen, back, joints, chest) or functions(e.g.. Menstruation, sexual intercourse, urination)

2 gastrointestinal sign: a history of at least 2 GI sign other than pain(e.g. nausea, bloating, vomiting, diarrhea, intolerance of several foods)

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CONTD….1 sexual sign: a history of at least one sexual or reproductive sign other than pain(e.g. sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)

1 Pseudo neurological sign: a history of at least 1 sign or deficit suggesting a neurological condition without pain(e.g. impaired coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, loss of touch or pain sensation, double vision, blindness, deafness, seizures, urinary retention.

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CONTD…C. Either (1) or (2):(1) symptoms not fully accounted for by a general medical condition or the effects of a substance

(2) when there is a related medical condition, the complaints and resulting social or occupational impairment exceed what would expected from the history, physical examination, or laboratory findings.

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CONTD….D. Symptoms are not internally feigned or produced, as in factitious disorder.

TREATMENT

PSYCHOTHERAPY

1.

Supportive psychotherapy: the treatment of choice is usually supportive psychotherapy. The first step is to enlist the patient in the therapeutic alliance by establishing a rapport. It is useful to demonstrate the link between psychosocial conflict(s) and somatic symptoms, if it is apparent.

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CONTD…In chronic cases, ‘symptom reduction’ rather than ‘complete cure’ might be a reasonable goal.

2. Behavior modification: after rapport is established, attempts at modifying behavior are made, for example, not focusing on the symptoms per se, and positively reinforcing normal functioning.

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CONTD3. Relaxation therapy, with graded physical exercises. PHARMACOTHERAPY:

DRUG THERAPY: antidepressant and/or benzodiazepines can be given on a short term basis for associated depression and/or anxiety.

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HYPOCHONDRIACAL DISORDERHypochondriasis is defined as persistent preoccupation with a fear(or belief) of having one (or more) serious disease(s), based on person’s interpretation of normal body function or a minor abnormality.

Causes:

1.Faulty interpretation of bodily cues and sensations as evidence of physical illness

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CONTD….2. Enhanced sensitivity to, and over-focusing on, physical sensations and illness cues

3. Stressful life events

4. Disproportionate incidence of disease in family during childhood

5. Secondary gains associated with the sick roles: decreased responsibility and increased attention

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DIAGNOSTIC CRITERIA(DSM IV-TR)Preoccupation with fear of having or belief that has a serious illness, based on misinterpretation of bodily sign or functions

Preoccupation persists despite appropriate medical evaluation, reassurance, and the person’s not developing the feared disease.

Preoccupation lasts at least 6 months.

Preoccupation causes clinically significant distress or impairment in important areas of functioning.

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CONTD….Preoccupation is not better accounted for by other disorders, such as GAD, OCD, panic disorder, major depression, separation anxiety, or another somatoform disorder.

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Epidemiology

.-

Men

are

affected

as

often

as

women

Average

age

of

onset

20 – 30

80 %

have

coexisting

major

depression

or

anxiety

disorder

.

Treatment

.-

--

Regulary

scheduled

visits

to

one

primary

care

physician

--SSRI

or

other

psychotropic

medications

.

--

Cognitive-behavioural

therapy

(CBT)

seems

to be

most

useful

of

psychoterapies

.-

Prognosis.-

Exacerbations

occur

commonly

under

stress.

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CONVERSION DISORDERIs a disorder in which the individual experiences one or more neurological symptoms that cannot be explained by any medical or neurological disorder.

Found in more women than men.

In women, sign are much more common on the left than the right side of the body

ONSET: late childhood through early adulthood; rarely before 10 or after 35 yrs.

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CONVERSION DISORDER:DIGNOSTIC CRITERIA(DSM IV-TR)

A- One or more sign or deficits affecting voluntary motor or sensory functioning and indicative of a neurological or other medical condition.

B- Psychological factors are associated with the sign- the initiation or exacerbation of sign is preceded by conflicts or stressors.

C- The sign not intentionally feigned or produced, as in factitious disorder or malingering.

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DIGNOSTIC CRITERIA(DSM IV-TR) CONTINUE’S and end.D- The sign cannot be fully explained by a general medical condition, the effects of a substance, or a culturally sanctioned behavior or experience.

E- Sign cause significant distress or impairment in functioning or warrant medical attention.

F- The sign is not limited to pain or sexual dysfunction, does not occur exclusively in the course of somatization disorder, and is not better accounted for by another mental disorder.

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CONVERSION DISODER:TREATMENT CONSIDERATIONS.

A. PSYCHOTHERAPY

Identify and attend to the traumatic or stressful life event.

Address current psychosocial stressors with environmental manipulation, support, coping skills.

Reduce any reinforcing or supportive consequences from the conversion sign.

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CONTINUEInsight-oriented therapies usually aren’t indicated or helpful.For acute sign: positive expectation for recovery; a face-saving way for the patient to recover ,e.g. physical therapy.

For chronic sign: physical rehabilitation, suggestion, and psychotherapy.

Work closely with a medical doctor and psychiatrist.

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CONVERSION DISORDER:ASSESSMENT

Assess the following

Physical sign, medical conditions,medications, abused substances, psychiatric symptoms, and stressors and conflicts.

The person’s level of medical knowledge.

Whether the person may be intentionally feigning symptoms.

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ASSESSMENT COUNTINUE’SManner of presenting symptoms-dramatic and histrionic or label indifference.R/O underlying neurological or general medical conditions by referral for a thorough neurological examination:5-10% have real medical problem.

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CONVERSION DISORDERPresentation

With motor sign or deficits-e.g. impaired coordination or balance, paralysis, localized weakness, difficulty swallowing, lump in throat, urinary retention.

With sensory sign or deficits-loss of touch or pain sensation, double vision, blindness, deafness, hallucinations.

With seizures or convulsion.

With mixed presentation.

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Body dysmorphic disorder

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Definition Body dysmorphic disorder (BDD) is a mental disorder characterized by the obsessive idea that some aspect of one's own appearance is severely flawed, defective, or misshapen and warrants exceptional measures to hide or fix it.

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Diagnosis After a medical evaluation to help rule out other medical conditions, your health care provider may make a referral to a mental health professional for further evaluation.

Diagnosis of body dysmorphic disorder is typically based on:

A psychological evaluation that assesses risk factors and thoughts, feelings, and behaviors related to negative self-image

Personal, social, family and medical history

Symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

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Physical and Psychiatric presenting symptomsMost common concerns involve facial flawsConstant mirror-checking

Attempt to hide the alleged deformity

Housebound

Avoids social situations

Causes impairment in their level of functioning

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TreatmentTreatment for body dysmorphic disorder often includes a combination of cognitive behavioral therapy( to help deal with stress of alleged imperfections as well as reality testing) and medications. Although there are no medications specifically approved by the Food and Drug Administration (FDA) to treat body dysmorphic disorder, medications used to treat other mental disorders, such as depression, can be effective. The use of SSRIs, TCAs.

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Differential diagnosisMedical: some types of brain damage, such as neglect syndromePsychiatric: anorexia, narcissistic personality disorder, OCD, Schizophrenia, delusional disorder

Slide37

Pain Disorders

Patients

with

pain

disorder

have

prolonged

,

severe

discomfort

without

an

adquate

medical

explanation

The

pain

often

coexists

with

a medical

condition

but

is

not

directly

caused

by

it

or

not

fully

accounted

for

by

it

Patients

often

have

a

history

of

multiple

visits

to

doctors

.

Slide38

Pain disorder, Dx and DSM-IV

Criteria

Patient

main

complaint

is

pain

at

one

or

more

anatomic

sites

, of

sufficient

severity

to warrant

clinical

attention

.

The

pain

causes

significant

distress

or

impairment

in

the

patient’slife

.

Psychological

factors

play

an

important

role in

the

pain

Not

intentionally

produced

Not

better

account

for

by

a mental

disorder

or

meet

criteria

for

dyspareunia

.

Slide39

Epidemiology

.-

Women

are 2 times as

likely

as

men

to

have

pain

disorder

.

Average

age

onset

30 – 50

High in

first

degree

relatives

.

Patients

have

hiher

incidence

of

major

depression

,

anxiety

disorder

, and

substance

abuse.

Treatment

and prognosis.-

SSRI,

Hypnosis

,

Psychoterapy

.

Analgesic

are

not

helpful

and

patients

often

become

dependent

on

them

.

Pain

disorder

usually

increase

in

intensity

for

the

first

several

months

and

often

becomes

chronic

and

disabling

.

Slide40

Factitious disorder

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Definition A disorder characterized by the conscious production of signs and symptoms of both medical and mental disorders.  Acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain a patient's role. 

The DSM-5 differentiates among two types:

Factitious Disorder Imposed on Self

Factitious Disorder Imposed on Another,

defined as:

When an individual falsifies illness in another, whether that be a child, pet or older adult

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Diagnosis

Diagnosing factitious disorder is often extremely difficult. People with factitious disorder are experts at faking many different diseases and conditions. And often they do have real and even life-threatening medical conditions, even though these conditions may be self-inflicted.

The

person's use of multiple doctors and hospitals, the use of a fake name, and privacy and confidentiality regulations may make gathering information about previous medical experiences difficult or even impossible.

Diagnosis

is based on objectively identifying symptoms that are made up, rather than the person's intent or motivation for doing so. A doctor may suspect factitious disorder when:

The person's medical history doesn't make sense

No believable reason exists for an illness or injury

The illness does not follow the usual course

There is a lack of healing for no apparent reason, despite appropriate treatment

There are contradictory or inconsistent symptoms or lab test results

The person resists getting information from previous medical records, other health care professionals or family members

The person is caught in the act of lying or causing an injury

To

help determine if someone has factitious disorder, doctors:

Conduct a detailed interview

Require past medical records

Work with family members for more information

Run only tests required to address possible physical problems

May use the criteria for factitious disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

Slide43

Physical and Psychiatric presenting symptoms

Possible warning signs of factitious disorders include:

Dramatic but inconsistent medical history

Unclear symptoms that are not controllable and that become more severe or change once treatment has begun

Predictable relapses following improvement in the condition

Extensive knowledge of hospitals and/or medical terminology, as well as the textbook descriptions of illness

Presence of many surgical scars

Appearance of new or additional symptoms following negative test results

Presence of symptoms only when the patient is with others or being observed

Willingness or eagerness to have medical tests, operations, or other procedures

History of seeking treatment at many hospitals, clinics, and doctors offices, possibly even in different cities

Reluctance by the patient to allow health care professionals to meet with or talk to family members, friends, and prior doctors

Typically demand treatment when in the hospital

If tests return negative, they tend to accuse doctors and threaten litigation

Becomes angry when confronted

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Treatment The first goal of treatment for a factitious disorder is to modify the person's behavior and reduce his or her misuse or overuse of medical resources. In the case of factitious disorder by proxy, the main goal is to ensure the safety and protection of any real or potential victims. Once the initial goal is met, treatment aims to work out any underlying psychological issues that may be causing the person's behavior.

The primary treatment for factitious disorders is psychotherapy. Treatment likely will focus on changing the thinking and behavior of the individual with the disorder (cognitive-behavioral therapy). Family therapy may also be helpful in teaching family members not to reward or reinforce the behavior of the person with the disorder.

There are no medications to treat factitious disorders themselves. Medication may be used, however, to treat any related disorder -- such as depression, anxiety, or a personality disorder. The use of medications must be carefully monitored in people with factitious disorders due to the risk that the drugs may be used in a harmful way.

Slide45

Differential diagnosisPsychiatric: other somatoform disorders, antisocial personality disorder, histrionic personality disorder, schizophrenia, substance abuse, malingering, and ganser’s syndrome.

Slide46

Malingering

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Definition The intentional production of “the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives

.”

Mañingering

involves the feign of physical or psychological symptoms in order to achieve personal gain.

Common external motivations include avoiding the police, receiving room and board, obtain narcotics, and receiving monetary compensation.

Slide48

DSM-IV-TR Considerations

According to the 

DSM-5

, malingering should be suspected in the presence of any combination of the following:

Medicolegal

presentation

(e.g.,

an

attorney refers

patient, a patient is

seeking compensation

for injury)

Discrepancy

between claimed

disability/distress

and

objective

findings

Lack of cooperation

during evaluation and in complying with prescribed treatment

Presence

of

Antisocial Personality Disorder

Slide49

Why Do People Malinger? Seen in both civil and criminal settings:

–

Civil:

1) personal injury

2) workers’ compensation

3) SSDI

In the civil context, it may benefit a plaintiff to appear emotionally and physically injured at the hands of the defendant

–

Criminal:

1) trial

competency

2) Insanity

3) diminished

actuality diminished actuality

4) sentencing

mitigation

5) death penalty

Used when a defendant determines it is in his/her best legal interests to be lacking certain abilities or to be suffering from emotional problems.

We commonly see blatant malingering of psychotic symptoms in competency and insanity cases (many times in the same persons).

Malingering

of cognitive deficits is common in competency cases and various civil cases

Slide50

Physical and Psychiatric presenting symptomsMost express subjective symptoms

Tend to complain a lot and exaggerate its effect on their functioning and lives

Preoccupied more with rewards than with alleviations of

symptoms

Patients usually present with multiple vague complaint that do not conform to a known medical condition.

They often have a long medical history with many hospital stay.

Slide51

They

are

generally

uncooperative

and

refuse

to

accept

a

good

prognosis

even

after

e

xtensive

medical

evaluation

.

Their

symptoms

improve

once

their

desired

objective

is

obtained

More

common

in

men

.

Slide52

If malingering is suspected, the clinician should consider the patient's possible reasons for secondary gain. Cues for the clinician include: If the patient has legal problems, potential for financial reward, or antisocial personality disorder; if the patient's story is incongruent with known facts or other informant accounts; if the patient will not cooperate while being evaluated.

Psychological evaluation is also recommended as a way to detect malingering. Psychologists have multiple assessment tools in addition to the clinical interview that are designed to provide objective, scientifically based information about whether an individual has responded honestly to the test, or whether he or she

has

exaggerated or minimized psychological problems (possibly to obtain an external incentive, such as money damages in a personal injury lawsuit).

Slide53

Differential diagnosisSomatoform disorders