Somatoform Disorders and Malingering

1. Somatoform Disorders and Malingering Vicken Y. Totten MD 7 December 2011

2. Goals and Objectives To review the traditional “contract” between physicians and patients To review illness and healing To review management of somatoform and factitious illnesses.

3. The contract • Patients feel “dis-ease” and want to feel “at ease” • Patients want physicians to relieve their “dis-ease” & provide them with wellbeing • Physicians want to “diagnose” first, treat second and comfort when they can. • Physicians want patients to actively seek and work towards their own wellbeing.

4. The disconnect • Patient dis-ease may not be caused by an illness • The patient’s illness may not fit within the doctors paradigms • Physicians are altruistic; they wish to “cure” and “help”; when they cannot, they are frustrated. • Frustrated physicians are uncomfortable and tend to blame the patient for the illness

5. Examples • Hysteria – a disease of the uterus • Treatment – hysterectomy & castration • Dysmenorrhea – caused by a woman’s non-acceptance of her place in society. • Treatment – psychotherapy • Fibromyalgia, reflex sympathetic dystrophy, cyclical vomiting, many psychiatric disorders, temporal lobe seizures, ergot poisoning and many more have been considered somatoform.

6. Differential • Munchausen's • Factitious disorder • Somatoform disorder • Malingering • Hypochondriasis • Conversion disorder • Chronic pain syndromes

7. Somatization per Rosen • “Somatization refers to a tendency to experience and communicate psychological distress as physical symptoms in the absence of identifiable pathology.” • Symptoms neither feigned nor under the voluntary control. • Often associated with depression & anxiety • May have “real” diseases, but complaints are out of proportion to the physical findings. • # sx rather than specific symptom indicates somatization

8. Concomitant Psychiatric disorders • Women (5); men (3) unexplained somatic complaints -> diagnosable psychiatric disorder 2x general populace. • Somatizers often alexithymiic • (“without words for mood”), resulting in alternative (somatic) forms of expression.[21] They steadfastly insist that their symptoms are caused by serious physical disorders even in the presence of conclusive evidence to the contrary.[8] Somatization may be unconsciously motivated by a desire to assume the

9. The “sick role” • Privileges and responsibilities. • Privileges: care from others; release from normal obligations; absolution from blame for their condition. • Responsibility: to actively try to get well; comply with recommendations; respond to treatment

10. Age effects • In children: headache, low energy levels, and recurrent abdominal pain are common; not usually indicative of severe social, psychiatric or emotional illness. • Pronounced polysymptomatic somatization may indicate increased risk

11. History • DSM-III and DSM-IV as “hysterical” and “hypochondriacal” neuroses. • 4 specific disorders • (1) somatization disorder, • (2) conversion disorder, • (3) pain disorder, • (4) hypochondriasis. • Prevalence of 0.06 to 2% among the general population and up to 9% among hospitalized patients

12. CRITERIA for Somatization (Rosen) •  Hx of medically unexplained physical symptoms beginning before the age of 30 years.   • All of the following: • Pain in at least 4 body sites (e.g., head, abdomen, back, joints, chest) or functions (e.g., during menstruation, during urination)   • > 2 GI symptoms other than pain • 1 or more sexual or reproductive symptom other than pain (e.g., sexual indifference, irregular menses)   • 1 or more sx or deficit suggesting a neurologic condition not limited to pain (e.g., paralysis, lump in the throat, blindness)   • Sx not explainable by any known medical condition or, are out of proportion to what might be reasonably expected.   • The symptoms must not be intentionally produced or feigned.

13. Impact • Only 33% of patients recover during 10- to 20-year follow-up, • New symptoms surface at least q year • A “lifetime of suffering,” -> normal life span • Health care costs 9x > than unaffected patients

14. Associations: • socioeconomic groups, • alcoholism and other addictions • poor education; • occupational, interpersonal, and marital problems.

15. Organic Diseases That May Be Mistaken For Somatoform Disorders •  Endocrine disorders: hyperparathyroidism, thyroid disorders, Addison's disease, insulinoma, pan-hypopituitarism   • Poisonings: botulism, carbon monoxide, heavy metals   • Porphyria   • Multiple sclerosis   • Systemic lupus erythematosus   • Wilson's disease  •  Myasthenia gravis  • Guillain-Barre syndrome  • Uremia

16. Conversion Disorder • AKA hysterical neurosis, conversion type • Often a single physiologically impossible condition. • Not voluntary • Most common in ED are pseudo-neurologic: pseudo seizures, syncope or coma, and paralysis or other movement disorders. • Belle indifference

17. Pain Disorder • Aka somatoform pain disorder • Distressful pain that • is not intentionally feigned • persistent in nature, • limits daily function, • involves one or more organ systems, • cannot be pathophysiologically explained.

18. Associated features • frequent physician visits • excessive use of analgesics, • requests for surgery, and • eventually the role of permanent invalid after the pain has forced the patient to discontinue gainful employment.

19. Hypochondriasis • From “regio hypochondriaca” because of the presumed splenic seat of the disorder • 4 characteristics: • physical symptoms disproportionate to demonstrable organic disease; • a fear of disease with a conviction that one is sick, leading to “illness-claiming behavior” (a compulsive insistence on being considered a physical cripple); ( • preoccupation with one's own body; • persistent and unsatisfying pursuit of medical care (doctor shopping) with a history of numerous procedures and surgeries and eventual return of symptoms. • Exaggerated awareness of normal physical signs or sensations • Does not respond to reassurance.

20. Hypochondriasis • Common (4-9% o general practice) • Expert at defeating the doctor • Age peaks: 30s-40s • Often “health nuts” • Induce negative feelings in physicians.

21. Somatoform and Hypochondriasis • Best care is a single, identified (and very patient!) primary care physician who can give the patient lots of attention and regular visits.

22. Factitious Disease and Malingering • We thank our readers sagacious • For reading our research auspicious • When the patient is hot • But the urine is not • The urine says “fever factitious”

23. Differentiating malingering from somatoform illness • Deliberate deception rather than unconscious. • Often associated with antisocial personality disorder • Deliberately hard to confirm their claims • More common in health care professionals

24. Factitious Disorders • Usually not initially considered • Dx delayed • Dx confounded by concomitant real illness

25. DX made when: • (1) the patient is accidentally discovered in the act, • (2) incriminating items are found, • (3) laboratory values suggest non-organic etiology, or • (4) the diagnosis is made by exclusion.

26. Malingering • Malingering for financial or drug gain is criminal behavior • Documentation must be made with care. • When coupled with drug seeking, may list many drug allergies. • Internet searchers make patients more sophisticated.

27. Characteristics of Malingering • Often has a medicolegal context • Marked discrepancy between the person’s claimed stress or disability and objective findings. • Poor cooperation during the diagnostic evaluation m, or poor compliance with prescribed treatments. • Person exhibits or has a Hx of antisocial behaviour.

28. Management • Depression heralds better response than personality disorder • Confrontation rarely effective • Therapeutic double bind: notify patient “that a factitious disorder may exist. The patient is further told that failure to respond fully to medical care would constitute conclusive evidence that the patient's problem is not organic but rather psychiatric. The problem is therefore reframed or redefined in such a way that (1) symptoms and their resolution are both legitimized and (2) the patient has little choice but to accept and respond to a proposed course of action or seek care elsewhere.” • This approach is not appropriate for the ED

29. Munchausen's • Essentially untreatable. Successful treatment is reportable. • So a thorough exam (often do not want complete exam) • Set limits, rule out life-threats. • The confronted patient usually disappears, only to reappear elsewhere

30. Munchausen's Syndrome by Proxy (MSBP) • Adult caregivers deliberately feign or create illness in a dependant child. • Primary concern is to protect the child. • At time of diagnosis and confrontation, there is high risk for maternal suicide.

31. Disposition • Out of home care for child victims of MSBP • Children returned to the home have 20% risk of death.

32. KEY CONCEPTS   • 2 broad diagnostic categories: • (1) those with obvious secondary gain (malingering), who control their actions, • (2) those with a motivation of achieving the sick role (factitious disorders), who cannot control their actions.   • ED management • a caring attitude • a search for objective clinical evidence of treatable medical or psychiatric illness. • Avoid unnecessary tests, medications, and hospitalizations in the absence of objective evidence of a medical or psychiatric disease • Refer for ongoing primary care.  • Victim protection takes first priority.

33. The Difficult Patient • Aka the “heart-sink patient” • More common in the ED than general medical practice • Usually have significant personality disorders or psychiatric disorders • Several classifications

34. One classification • Dependent patients • Entitled patients • Intractable patients • Self-destructive patients

35. Dependant patients • Excessive need for attention, reassurance, analgesia • Use helplessness and seduction as strategies. • Physician initially feels special, then drained and frustrated. • Patient needs increase when ultimately rejected

36. Dependent patients, traditional diagnostic categories • Personality disorders: dependent, histrionic, borderline personality • Malingerers, chronic psychiatric patients • Management: Try to view the patient's neediness as a symptom. Be supportive while setting limits on patient expectations. • Follow-up with appropriate, consistent physician.

37. Entitled Patients • Fear of loss of power causes entitled behavior. • Uses intimidation, name dropping, hostility, and threats. • Physician feels intimidated, angry, sometimes inadequate. • Potential for litigation.

38. Entitled Patients • Personality disorders: paranoid, narcissistic • Substance abusers • VIPs

39. Entitled Patients (Management) • Be supportive of entitlement to good care while setting limits on unreasonable demands. • Allow patients to choose between reasonable treatment options. • Avoid power struggles.

40. Intractable Patients (dx) • Excessive needs for attention met by having unsolvable problems with multiple visits, doctor shopping, poor compliance, and no hope for successful treatment. • Physician feels frustrated, angry, but fears “sharing” pessimism and missing significant illness. • Cycle of “help me, but nothing helps.”

41. Intractable Patients (behaviors) • Personality disorders: antisocial, borderline • Malingerers

42. Intractable Patients (management) • Distinguish from other complicated patients, and manage appropriately. • Beware of cognitive distortions that may obscure significant illness. • Be supportive while setting reasonable expectations.

43. Self-Destructive Patients • Disregard for own health and repeated visits for serious illness. • Often overtly self-destructive, denying of illness. • Physicians feel frustrated, helpless, angry, and guilty for wishing the patient success.

44. Self-Destructive Patients • Chronically suicidal patients • Substance abusers • Borderline personality disorder

45. Self-Destructive Patients • Provide appropriate medical care. • Learn to deal with own negative and nihilistic reactions to patients. • Look for signs of depression and consider psychiatric referral as needed.

46. KEY CONCEPTS • Difficult patients may elicit negative reactions in caregivers, resulting in undesirable implications for both themselves and their caregivers.  • Managing the difficult patient can be optimized by understanding the multiple factors contributing to the impaired physician-patient relationship.

47. Key Concepts: • Behavioral classifications should be used instead of pejorative stereotypes when characterizing difficult behaviors. • General and specific strategies, including understanding our own reactions, are helpful in dealing with the impaired physician-patient relationship. 

48. Key Concept • The ability to accept difficult behaviors as symptoms and treat even the most difficult patient with kindness is central to providing good care while avoiding personal frustration, medicolegal repercussions, and physician burnout.

49. Final word: • You can’t choose your patients • You CAN choose how you react • Take care of yourself first.