Differentiating Somatoform Disorder, Factitious Disorder an - PowerPoint Presentation

Slide1

Differentiating Somatoform Disorder, Factitious Disorder and Malingering

Practical Strategies Conference

June 11, 2015

Dr. William H.

Gnam

, PhD, MD, FRCPC

Psychiatrist

w

illiam.gnam@gmail.comSlide2

Outline

Introduction:

The diagnostic

m

ethods of psychiatry

Clinical Descriptions and Essential Features

Diagnostic Criteria: DSM-IV vs. DSM-5

The Changing Conception of Conversion Disorder

Factitious Disorder: updated diagnostic criteria

Malingering and motivation

Practical Strategies for Differentiating

ConclusionsSlide3

Introduction (1)

The Diagnostic Manuals for Mental Disorders emphasize standardized, reproducible methods

Diagnoses are confirmed on the basis of symptoms (primarily), signs (secondarily)

Emphasis on reportable or observable criteria is intended to increase objectivity and reproducibilitySlide4

Introduction (2)

In North America, the dominant diagnostic system is the Diagnostic and Statistical Manual of Mental Disorders (DSM), 1

st

through 5

th

editions

Diagnoses are defined according to specific diagnostic criteria, with rules for necessary and sufficient criteria

The most valuable property of the DSM system is the potential to provide reliable (reproducible) diagnosesSlide5

Introduction (3)

For many important diagnoses in the DSM-IV, (e.g. Major Depressive Disorder), good reliability has been established scientifically

With the DSM-5, less reliability data, some evidence that important diagnoses lack acceptable reliabilitySlide6

Introduction (4)

In contrast with the “rational” methods for diagnosis of many mental disorders, confirming the diagnoses of Conversion, Factitious Disorder and Malingering requires:

Difficult exclusions (Conversion Disorder)

Inferences based upon external data, not exclusively patient self-report

Very difficult judgments about motivationSlide7

Conversion Disorder (1)

Essential features are:

The presence of symptoms or deficits affecting voluntary motor or sensory functioning

The symptoms or deficits cannot be fully explained by a neurological or general medical condition – and are incompatible with a neurological condition or disease

The symptoms/deficits typically do not conform to anatomical pathways or physiological mechanisms, and

may not be consistent

Slide8

Conversion Disorder (2)

Estimates of the prevalence of Conversion Disorder:

from 11/100,000 to 500/100,000

Onset is generally (but not exclusively) acute

Recurrence is common:

25% within the first year

Risk factors: maladaptive personality traits, history of childhood abuse/neglect, stressful life events (not always present)Slide9

Conversion Disorder (3)

There were problems with the diagnosis of Conversion Disorder defined in DSM-IV:

Required confirmation that psychological factors contributed, but factors were poorly defined and not always present

Required confirmation that feigning / intentional symptom production is excluded, but such exclusions are often not reliableSlide10

Conversion Disorder (4)

The DSM-5 represents a

major revision

of the diagnostic criteria for Conversion DisorderSlide11

Conversion Disorder(5):Major Changes in Diagnostic Criteria

DSM - IV

One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological disorder/general medical condition symptom(s)

The symptom cannot be fully explained by a general medical condition

DSM - 5

One or more symptoms of altered motor or sensory function

Evidence of incompatibility between the symptom and recognized neurological conditionsSlide12

Conversion Disorder(6):Major Changes in Diagnostic Criteria

DSM - IV

Psychological factors are judged to be associated with the symptom or deficit

The symptom or deficit is not intentionally produced or feigned

DSM - 5

(This criterion dropped)

(Dropped.)

The symptom or deficit is not better explained by another medical or mental disorderSlide13

Conversion Disorder (7)

The revised criteria have major practical implications:

More emphasis on eliciting medical evidence of

incompatibility

with known neurological conditions

The onerous requirement to

exclude

feigning is dropped (but still must consider a better explanation)

Dropped requirement for associated psychological factors, consistent with empirical studiesSlide14

Conversion Disorder (8)

Another very important implication/ acknowledgement:

“The diagnosis of conversion disorder does not require the judgment that the symptoms are not intentionally produced (i.e., not feigned), as the definitive evidence of feigning may not be reliably discerned” (DSM-5, page 320)Slide15

Factitious Disorder (1)

Essential Features:

Intentional production or feigning of physical or psychological symptoms

External incentives (such as economic gain, avoiding legal responsibilities) are absent

(The motivation for the

behaviour

is to assume the sick role.)Slide16

Factitious Disorder (2)

There is very limited evidence on prevalence, but factitious disorders are

very rare

In large general hospitals, about 1% of inpatients for whom there is psychiatric consultation are diagnosed are diagnosed with Factitious Disorder

Onset usually in early adulthood, course characterized by (repeated) intermittent episodes, often after hospitalization for a general medical condition or psychiatric disorderSlide17

Factitious Disorder (3)

P

ublished case series suggest a strong association with severe dysfunctional personality characteristics

The intentional production of symptoms or feigning can mimic a wide range of medical conditions or psychological symptoms, not just motor or sensory symptoms/deficitsSlide18

Factitious Disorder (4)

What limited data that exists suggests that persons with Factitious Disorder

do not

experience their motive to be the need to assume the sick role

The DSM-5 contains a

significant

revision of the diagnostic criteria for Factitious Disorder:Slide19

Factitious Disorder(5):Changes in Diagnostic Criteria

DSM - IV

Intentional production or feigning of physical or psychological signs or symptoms

The motivation for the

behaviour

is to assume the sick role

DSM - 5

Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception

(

Dropped

as a criterion: but stipulates that

behaviour

is not better explained by another mental disorder)Slide20

Factitious Disorder(6):Changes in Diagnostic Criteria

DSM - IV

External incentives for the

behaviour

(such as economic gain, etc.) are absent

(Not explicitly stated)

DSM - 5

The deceptive

behaviour

is evident even in the absence of obvious external incentives

The individual presents himself or herself to others as ill, impaired, or injuredSlide21

Factitious Disorder (7)

The revised criteria have some practical implications:

More emphasis on the objective identification of falsification of signs and symptoms of illness, rather than inference about intent or possible underlying motivation.

The revised criteria do not imply that factitious disorder

behaviours

could never occur in the presence of external incentives, but does stipulate that they persist even when obvious external rewards/incentives are absent.Slide22

Malingering (1)

Malingering is a massive topic and not the focus of the current presentation

Malingering has never been considered to be a mental disorder

The essential feature of Malingering definitions is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentivesSlide23

Malingering (2)

The limited data on Malingering indicates that the prevalence is not high, but from a societal perspective the prevalence is nonetheless significant

The definition of Malingering has not changed significantly between the DSM-IV and DSM-5.Slide24

Malingering (3)

Despite the attempts of the DSM-5 to remove criteria that require inference about motivation, the DSM-5 description of Malingering emphasizes that the motivation for the symptom production is an external incentive

The difficulties in determining motives acknowledged in other disorders are no easier in MalingeringSlide25

Malingering (4)

There are difficulties with the DSM and other discussions of Malingering:

Failure to distinguish between other motivation for conscious symptom production/exaggeration (e.g., “cry for help”)

Lack of acknowledgement of the difficulties in determining motivation clinicallySlide26

Differentiating: Practical Strategies (1)

The changes in diagnostic criteria correctly imply that clinical assessment should focus on accurately identifying

behaviours

, and gathering evidence about incompatibility with medical conditions, and not should not speculate/infer motive

This change does not imply that differentiating between Conversion, Factitious Disorder and Malingering (or other conscious symptom production) is not possible in many casesSlide27

Differentiating: Practical Strategies (2)

Factitious Disorder can be

excluded in most cases

involving disability after acute traumatic injury (MVAs, work accidents), because

Factitious Disorders are very rare

They can involve

behaviours

that produce non- conversion symptoms

They become manifest mostly in inpatient settings

The natural history is repeated episodes over time, usually established before a traumatic event

They do not occur repeatedly or predominantly with obvious external incentivesSlide28

Differentiation: Practical Strategies (3)

Distinguishing between “Malingering” and Conversion Disorder based upon a single clinical encounter is difficult or impossible, but this should not preclude a “working” diagnosis of Conversion Disorder in cases of genuine uncertainty

Malingering vs. Conversion cannot be reliably distinguished by minor inconsistencies in the symptom/deficit, as such inconsistencies are common to bothSlide29

Differentiation: Practical Strategies (4)

Distinguishing between Conversion vs. “Malingering” cannot be reliably accomplished by identification of external incentives or risk factors, as none are sensitive or specific enough to discriminate reliablySlide30

Differentiation: Practical Strategies (5)

Distinguishing between Conversion vs. “Malingering” is best accomplished with longitudinal clinical data provided by extensive documentation review, by collateral examination for symptom production (such as neuropsychological testing), and by repeated observations

However, in some cases uncertainty is inevitable and may persist for years or indefinitelySlide31

Summary (1)

The diagnoses of Factitious Disorder, Conversion and Malingering have often been unreliable due to inference / speculation about motive

Major changes in the diagnostic criteria for Conversion Disorder and Factitious Disorder improve the practical procedures to make these diagnoses by removing reference to motivationSlide32

Summary (2)

Excluding Factitious Disorder is usually straightforward in cases involving acute injury, especially when external incentives are persistently present, or when a history of repeated disturbance while in hospital is absent

There is no straightforward clinical method to distinguish between Conversion Disorder and Malingering, which is acknowledged for the first time in the DSM-5.Slide33

Summary (3)

While in many cases Conversion Disorder vs. Malingering can be differentiated by the consistency of evidence and presentation over time, in some (rare) cases the uncertainty will persist.

The DSM and other discussions of Malingering often involve unwarranted assumptions regarding motivation that are likely simplistic