2. Objectives: Somatoform disorders
Identify the diagnostic features of the most
common somatoform disorders
List characteristics differentiating somatoform
disorders from malingering and factitious
disorders
Outline management strategies for patients with
somatoform disorders.
By the conclusion of the presentation, the student
will be able to:
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4. Ms. A
Ms. A is a 43 year old divorced woman who
complains of abdominal pain. She describes
a searing pain that usually follows meals, and
localizes it by pointing to an area just above
her umbilicus. She insists that antacids and
ranitidine are of no help. She is insistent on
having an endoscopy right away.
Ms. A’s chart is now on its third volume. She
has made frequent visits to the practice over
about 20 years, sometimes for this complaint
and sometimes for others. She has had
multiple diagnostic procedures, and many
trials of therapy. None has brought definitive
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9. Screening criteria II - 2 of:
Vomiting
Pain in extremities
Dyspnea without exertion
Amnesia
Dysphagia
Burning sensation in sexual organs or rectum
Painful menstruation
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10. Frequency of common symptoms
in somatization disorder
See Andreasen & Black (4th Ed.), Table 8-3
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11. Ms. A - 2
You remind Ms. A that she had an upper GI
series of X-ray studies less than a year ago,
and an upper endoscopy about six months
ago. The complaints were identical then, and
the results were negative. You begin to make
some recommendations about changes in
eating patterns, when she interrupts.
“I’ve tried all that and it doesn’t work. I know
I have an ulcer and the exams last year were
negative because they missed it. I never had
much faith in that gastroenterologist you
referred me to, anyway. You’ve got to find
someone who can make the diagnosis and
take care of it properly.”
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12. Hypochondriasis
Generalized fear of or belief in illness
Prevalence in men = women
Pervasive disruption of psychosocial
function
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14. Pain disorder
Pain in one or more sites
Psychological factors in
origin and/or
maintenance of pain
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15. Body dysmorphic disorder
Preoccupation with imagined or
slight imperfection in appearance
– Most commonly: skin, hair, nose
– Also: penis, muscles, breasts,
buttocks
Men = women
Some family link to OCD
SSRIs modestly helpful with
quality of life
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16. Conversion disorder
Loss of, or alteration in, physical function,
resulting from psychologic need or conflict
Historical roots
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21. A. insistence on the presence of a particular illness.
B. large variety of unsubstantiated physical
complaints.
C. persistent complaints of pain with
disproportionate disability.
D. personality style featuring physical manifestations
of psychological problems.
E. sensory or motor symptoms suggesting
neurologic origin.
The defining characteristic of conversion disorder is:
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22. A. insistence on the presence of a particular illness.
B. large variety of unsubstantiated physical
complaints.
C. persistent complaints of pain with
disproportionate disability.
D. personality style featuring physical manifestations
of psychological problems.
E. sensory or motor symptoms suggesting
neurologic origin.
The defining characteristic of conversion disorder is:
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23. Sensory or motor symptoms suggesting
neurologic origin
Positive evidence of psychologic etiology
See Andreasen & Black (4th Ed.), Table 8-5 for DSM-IV
criteria
Conversion disorder
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25. A. Both are different names for the same condition.
B. Factitious disorder attempts to achieve psychological
benefit, malingering attempts to achieve external
benefit.
C. Factitious disorder is conscious, malingering is primarily
unconscious.
D. Malingering is a much more chronic condition than
factitious disorder.
E. Malingering patients complain of a wider variety of
symptoms.
The chief difference between malingering and
factitious disorder is:
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26. A. Both are different names for the same condition.
B. Factitious disorder attempts to achieve
psychological benefit, malingering attempts to
achieve external benefit.
C. Factitious disorder is conscious, malingering is primarily
unconscious.
D. Malingering is a much more chronic condition than
factitious disorder.
E. Malingering patients complain of a wider variety of
symptoms.
The chief difference between malingering and
factitious disorder is:
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27. Diagnostic algorithm
Suspicious symptoms
or complaints
Conscious attempt
to deceive
No conscious
attempt to deceive
Somatoform disorders, e.g.:
Somatization disorder
Conversion disorder
Hypochondriasis
Chief goal
psychological
(primary gain)
Factitious
disorder
Chief goal external
(secondary gain)
Malingering
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28. Primary gain Solution to an
internal problem
Secondary gain Environmental
influences that
perpetuate somatization
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29. Factitious Disorder
Production of symptoms under voluntary
control
− Worsen when observed
− Bizarre or ridiculous
− Wax and wane with environmental events
Goal is to assume “patient role”
External incentives absent
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30. Malingering: DSM-IV (V65.2)
Intentional production of
false or grossly
exaggerated symptoms,
motivated by external
incentives such as
obtaining financial
compensation or drugs, or
avoiding work, military
duty, or criminal
prosecution
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31. Malingering
Symptoms under voluntary control
− Patient acknowledgement
− Direct observation
− Failure to cooperate with treatment
− Rapid remission when incentives removed
Causal relationship to environmental incentive
− Avoidance of work, punishment, military service
− Financial gain
− Acquisition of drugs
Cannot be explained by desire to assume
patient role, or by other mental disorder
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39. Management of somatoform
disorders
Explain chronic nature of condition
Explore impact on patient’s life
Avoid implying “It’s all in your head.”
Explain tension ↔ pain cycle
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41. Management of somatoform
disorders
•Explain chronic nature of condition
•Explore impact on patient’s life
•Avoid implying “It’s all in your head.”
• Explain tension ↔ pain cycle
•Brief physical exam
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