Somatoform Disorders and Malingering

Vicken Y. Totten MD

7 December 2011

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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.

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The contractPatients 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.

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The disconnect

Patient dis-ease may not be caused by an illnessThe patient’s illness may not fit within the

doctors paradigmsPhysicians 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

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ExamplesHysteria – a disease of the uterusTreatment – hysterectomy & castrationDysmenorrhea – caused by a woman’s non-

acceptance of her place in society. Treatment – psychotherapyFibromyalgia, reflex sympathetic dystrophy,

cyclical vomiting, many psychiatric disorders, temporal lobe seizures, ergot poisoning and many more have been considered somatoform.

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Differential

Munchausen's Factitious disorderSomatoform disorderMalingeringHypochondriasisConversion disorderChronic pain syndromes

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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

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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

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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

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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

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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

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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.

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Impact

Only 33% of patients recover during 10- to 20-year follow-up,

New symptoms surface at least q yearA “lifetime of suffering,” -> normal life

spanHealth care costs 9x > than unaffected

patients

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Associations:

socioeconomic groups,alcoholism and other addictionspoor education; occupational, interpersonal, and marital

problems.

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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

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Conversion Disorder

AKA hysterical neurosis, conversion typeOften a single physiologically impossible

condition. Not voluntaryMost common in ED are pseudo-neurologic:

pseudo seizures, syncope or coma, and paralysis or other movement disorders.

Belle indifference

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Pain Disorder

Aka somatoform pain disorderDistressful pain that

is not intentionally feignedpersistent in nature, limits daily function, involves one or more organ systems, cannot be pathophysiologically explained.

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Associated features

frequent physician visitsexcessive use of analgesics, requests for surgery, and eventually the role of permanent invalid

after the pain has forced the patient to discontinue gainful employment.

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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.

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Hypochondriasis

Common (4-9% o general practice)Expert at defeating the doctorAge peaks: 30s-40sOften “health nuts”Induce negative feelings in physicians.

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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.

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Factitious Disease and Malingering

We thank our readers sagaciousFor reading our research auspiciousWhen the patient is hotBut the urine is notThe urine says “fever factitious”

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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

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Factitious Disorders

Usually not initially consideredDx delayedDx confounded by concomitant real

illness

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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.

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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.

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Characteristics of Malingering

Often has a medicolegal contextMarked 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.

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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

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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

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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.

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Disposition

Out of home care for child victims of MSBP

Children returned to the home have 20% risk of death.

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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.

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The Difficult Patient

Aka the “heart-sink patient”More common in the ED than general

medical practiceUsually have significant personality

disorders or psychiatric disordersSeveral classifications

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One classification

Dependent patientsEntitled patientsIntractable patientsSelf-destructive patients

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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

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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.

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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.

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Entitled Patients

Personality disorders: paranoid, narcissistic

Substance abusers VIPs

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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.

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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.” 40

Intractable Patients (behaviors)

Personality disorders: antisocial, borderline

Malingerers

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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.

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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.

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Self-Destructive Patients

Chronically suicidal patientsSubstance abusers Borderline personality disorder

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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.

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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.

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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. 

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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.

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Final word:

You can’t choose your patientsYou CAN choose how you reactTake care of yourself first.

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