Somatoform Disorders, Factitious Disorders, and Malingering

I. Introduction

These disorders involve the appearance of symptoms of disease or belief one has a disease or deformity, despite the absence of one. They are often a challenge to detect and treat. They capture a range of both manipulative and unconscious production of symptoms to fulfill various psychological needs, as well as intrusive, focused, worry with respect to the appearance, health, or physical condition of one’s body.

II. Somatoform Disorders

The term somatoform disorder is derived from the Greek soma for body, and these disorders are distinguished by physical signs and symptoms that suggest a medical condition; however, on examination, they cannot be fully explained by any known medical illness. The symptoms are severe enough to cause the patient significant distress or functional impairment. These tend to be chronic and respond to a consistent psychotherapeutic treatment alliance and support.

Five specific somatoform disorders are recognized in Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR): somatization disorder, conversion disorder, hypochondriasis, body dysmorphic disorder, and pain disorder. Two residual diagnostic categories in DSM-IV-TR are undifferentiated somatoform disorder and somatoform disorder not otherwise specified. Table 16-1 summarizes the clinical features of the different somatoform disorders, which are discussed separately below.

A. Somatization disorder.

Somatization disorder is characterized by ongoing reporting and experience of a range of physical symptoms that are not medically well explained and yet cause significant impairment and/or result in multiple attempts at medical intervention.

Epidemiology
- Lifetime prevalence in the general population is 0.1% to 0.5%.
- Women outnumber men by a 5:1 ratio.
- Lifetime prevalence is 1% to 2% of all women.
- More common in less well-educated persons and persons of low socioeconomic status.
- Usual onset is in adolescence and young adulthood.

Etiology

Psychological—suppression or repression of anger toward others, with the turning of anger toward self, can account for symptoms. Low self-esteem is common. Identification with parent who models sick role. Some dynamic similarity to depression.

Table 16-1 Clinical Features of Somatoform Disorders

Diagnosis	Clinical Diagnostic Presentation	Demographic and Epidemiological Management Features	Features	Associated Strategy	Differential Prognosis	Contributing Disturbances	Primary for Symptom Presentation	Psychological Processes to Symptoms	Motivation Production
Somatization disorder	Polysymptomatic Recurrent and chronic Sickly by history	Young age Female predominance 20:1 Familial pattern 5%–10% incidence in primary care populations	Review of systems profusely positive Multiple clinical contacts Polysurgical	Therapeutic alliance Regular appointments Crisis intervention	Poor to fair	Histrionic personality disorder Antisocial personality disorder Alcohol and other substance abuse Many life problems Conversion disorder	Physical disease Depression	Unconscious Cultural and developmental	Unconscious psychological factors
Conversion disorder	Monosymptomatic Mostly acute Simulates disease	Highly prevalent Female predominance Young age Rural and low social class Little-educated and psychologically unsophisticated	Simulation incompatible with known physiological mechanisms or anatomy	Suggestion and persuasion Multiple techniques	Excellent except in chronic conversion disorder	Alcohol and other substance dependence Antisocial personality disorder Somatization disorder Histrionic personality disorder	Depression Schizophrenia Neurological disease	Unconscious Psychological stress or conflict may be present	Unconscious psychological factors
Hypochondriasis	Disease concern or preoccupation	Previous physical disease Middle or old age Male to female ratio equal	Disease conviction amplifies symptoms Obsessional	Document symptoms Psychosocial review Psychotherapeutic	Fair to good Waxes and wanes	Obsessive–compulsive personality disorder Depressive and anxiety disorders	Depression Physical disease Personality disorder Delusional disorder	Unconscious Stress—bereavement Developmental factors	Unconscious psychological factors
Body dysmorphic disorder	Subjective feelings of ugliness or concern with body defect	Adolescence or young adult Female predominance Largely unknown	Pervasive bodily concerns	Therapeutic alliance Stress management Psychotherapies Antidepressant medications	Unknown	Anorexia nervosa Psychosocial distress Avoidant or obsessive–compulsive personality disorder	Delusional disorder Depressive disorders Somatization disorder	Unconscious Self-esteem factors	Unconscious psychological factors
Pain disorder	Pain syndrome simulated	Female predominance 2:1 Older: 4th or 5th decade Familial Up to 40% of pain populations	Simulation or intensity incompatible with known physiological mechanisms or anatomy	Therapeutic alliance Redefine goals of treatment Antidepressant medications	Guarded, variable	Depressive disorders Alcohol and other substance abuse Dependent or histrionic personality disorder	Depression Psychophysiological Physical disease Malingering and disability syndrome	Unconscious Acute stressor developmental Physical trauma may predispose	Unconscious psychological factors
Adapted from Folks DG, Ford CV, Houck CA. Somatoform disorders, factitious disorders, and malingering: In: Stoudemire A, ed. Clinical Psychiatry for Medical Students. Philadelphia: Lippincott, 1990:233.

Genetic—positive family history; present in 10% to 20% of mothers and sisters of affected patients; twins—concordance rate of 29% in monozygotic and 10% in dizygotic twins.

Laboratory and psychological tests. Minor neuropsychological abnormality in some patients (e.g., faulty assessment of somatosensory input).
Pathophysiology. Prolonged use of medications such as painkillers or other treatments given in response to patients seeking medical attention may increase the risk of adverse effects of those medications. Some data indicate that abnormal regulation of cytokines—messengers affecting immune system—may be involved in nonspecific symptoms reported with the disease such as fatigue, anorexia, and other features.

Diagnosis, signs, and symptoms

Many somatic complaints with complicated medical histories.
The most common complaints are pain, gastrointestinal symptoms, sexual complaints, and neurological signs (e.g., dizziness, amnesia).
Suicidal ideation often present, but suicide is rare.
Depression or anxiety related to complaints may be present; interpersonal problems are frequent. See Table 16-2.

Table 16-2 DSM-IV-TR Diagnostic Criteria for Somatization Disorder

A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:
1. four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
2. two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
3. one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
4. one pseudoneurologic symptom: a history of at least one symptom or deficit suggesting a neurologic condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)
Either (1) or (2):
1. after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings
The symptoms are not intentionally feigned or produced (as in factitious disorder or malingering).

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.

Differential diagnosis. Distinguishing features of actual medical conditions that might help exclude their consideration in these patients include:
- Multiple sclerosis: muscular weakness throughout body.
- Chronic fatigue syndrome: Epstein-Barr virus may be present.
- Porphyria: abdominal pain, red urine.
- Schizophrenia: thought disorder, hallucinations. Somatic delusions may be present.
- Panic attacks: intermittent, episodic. Symptoms of anxiety or panic.
- Conversion disorder: characterized by few symptoms with clearer symbolic meaning.
- Factitious disorder: conscious faking of symptoms to achieve role of patient; usually eager to be in hospital.
- Pain disorder: pain is usually the only complaint.
Course and prognosis. Chronic course with few remissions; however, severity of complaints can fluctuate. Complications include unnecessary surgery, repeated medical workups, substance dependence, and adverse effects of unnecessary prescribed drugs. Depression is frequent.
Treatment
- Pharmacological: avoid psychotropics, except during period of acute anxiety or depression, because patients tend to become psychologically dependent. Antidepressants are useful in secondary depression.
- Psychological: long-term insight or supportive psychotherapy is required to provide understanding of dynamics, support through distressing life events, or both; important to follow patient to prevent substance abuse, doctor shopping, unnecessary procedures, and diagnostic tests.

B. Conversion disorder

Definition. Characterized by involuntary alteration or limitation of voluntary motor or sensory functioning that results from psychological conflict or need (previously known as hysteria).
Epidemiology
- Incidence and prevalence: 10% of hospital inpatients and 5% to 15% of all psychiatric outpatients.
- Age: early adulthood, but can occur in middle or old age.
- Occurs in twice as many women as in men.
- Family history: more frequent in family members.
- More common in persons of low socioeconomic status and less well-educated persons.
Etiology
- Biological
  - Symptoms depend on activation of inhibitory brain mechanisms.
  - Excessive cortical arousal triggers inhibitory central nervous system (CNS) mechanisms at synapses, brainstem, and reticular activating system that may account for sensory deficits.
  - Increased susceptibility in patients with frontal lobe trauma or other neurological deficits.
- Psychological
  - Expression of unconscious psychological conflict that is repressed.
  - Premorbid personality disorder—avoidant, histrionic.
  - Impulse (e.g., sex or aggression) is unacceptable to ego and is disguised through symptoms.
  - Identification with family member who has same symptoms caused by real disease; learned in childhood.
- Psychodynamics
  - La belle indifférence is a lack of concern about illness or obvious impairment and is present in some patients.
  - Primary gain refers to the reduction of anxiety by repression of an unacceptable impulse. Symbolization of impulse onto symptom thus occurs (e.g., paralysis of arm prevents expression of aggressive impulse).
  - Secondary gain refers to benefits of illness (e.g., compensation from lawsuit [compensation neurosis], avoidance of work, dependence on family). Patient usually lacks insight about this dynamic.
  - Other defense mechanisms as source of symptoms: reaction formation, denial, displacement.
Laboratory and psychological tests
- Evoked potentials show disturbed somatosensory perception; diminished or absent on side of defect.
- Mild cognitive impairment, attentional deficits, and visuoperceptual changes on Halstead-Reitan Battery.
- Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Rorschach test show increased instinctual drives, sexual repression, and inhibited aggression.
- Drug-assisted interview—intravenous amobarbital (Amytal) (100 to 500 mg) in slow infusion often causes conversion symptoms to abate. For example, patient with hysterical aphonia will begin to talk. Test can be used to aid in diagnosis but is not always reliable.
Pathophysiology. No changes; some brain imaging studies show hypometabolism in the dominant hemisphere and hypermetabolism in the nondominant hemisphere.

Diagnosis, signs, and symptoms. See Table 16-3.

Motor abnormalities—paralysis, ataxia, dysphagia, vomiting, aphonia.
Seizure symptoms—pseudoseizures, unconsciousness.
Sensory disturbances—blindness, deafness, anosmia, anesthesia, analgesia, diplopia, glove-and-stocking anesthesia (does not follow known sensory pathways).
Close temporal relationship between symptom and stress or intense emotion.
Left-sided symptoms more common than right-sided symptoms.
The person is not conscious of intentionally producing the symptoms.