Robert P. Roca
Illness Behavior and Somatization
People who consult health care practitioners are expected to have discernible pathologic or pathophysiologic abnormalities (i.e., disease) accounting for their symptoms. The magnitude of their complaints and the associated disability are expected to be proportional to the disease diagnosed. They are supposed to pursue and cooperate with medical care and to resume normal social functioning as soon as possible. This sequence of responses is called normal illness behavior (1).
Sometimes there is a discrepancy between diagnosable disease and the magnitude and duration of symptoms and disability. Patients may complain of weakness or pain in the absence of objective findings. They may have pseudoseizures. They may visit their health care practitioners repeatedly with fears of having acquired immunodeficiency syndrome (AIDS) despite several negative human immunodeficiency virus (HIV) serology results and normal physical examinations. Such responses are examples of abnormal illness behavior.
Explaining discrepancies between objective evidence of disease and the subjective experience of symptoms is a major concern of psychosomatic medicine and an active area of research. It is speculated that “unexplained somatic symptoms” may in some cases result from functional disturbances of the central nervous system that may be possible to demonstrate in the future using functional central nervous system (CNS) imaging techniques (2). It is also believed that some patients with unexplained somatic symptoms may be manifesting somatization, a phenomenon in which physical symptoms are linked to psychological factors or conflicts. Its mechanisms are incompletely understood, but factors promoting somatization can often be discovered in individual cases.
Why Patients Somatize
Explanations of somatization come from at least four distinct perspectives: Somatization may be viewed as a product of disease, a manifestation of personality, a modeled or reinforced behavior, or an understandable product of a patient's life story. Each perspective calls for different observations and illuminates different aspects of the phenomenon of somatization.
Somatization as a Symptom of Disease
Somatization may occur as a symptom of a psychiatric disorder, particularly major depression, panic disorder, schizophrenia, or dementia. Sometimes somatic symptoms are the only complaints that patients with these conditions present to their health care practitioners (3).
As noted above, unexplained physical symptoms may in some cases be caused by as yet uncharacterized “functional disturbances of the nervous system” (2); this is a speculative proposal without firm empirical support at this time. There is no doubt that unexplained symptoms may also be caused by clear-cut medical conditions that have simply not yet been diagnosed—even when the symptoms seem to be expressing a psychological conflict or need. Studies of one subset of somatizing patients—those originally diagnosed as hysterics—have shown that up to 30% may ultimately be found to have medical or neurologic disorders
P.294
that, in retrospect, explain the presenting hysterical symptoms (4). On the other hand, a general tendency to complain of somatic symptoms may be negatively correlated with the presence of particular specific pathologic entities (e.g., coronary artery disease [CAD]) (5). Furthermore, the greater the number of unexplained somatic symptoms (e.g., pain complaints), the greater the likelihood of a diagnosable psychiatric disorder such as major depression (6).
Somatization as a Manifestation of Personality
The concept of personality implies enduring attitudes and habitual patterns of response. Personalities may be viewed as approximations of ideal prototypes (e.g., histrionic, obsessive-compulsive) or as clusters of individual traits (e.g., dependency, assertiveness), as discussed inChapter 23. Somatization has been associated with personality viewed in both of these ways. Patients with a histrionic or an obsessive-compulsive personality type may be predisposed to develop, respectively, somatization disorder or hypochondriasis (see later sections on these disorders). Patients with prominent traits of introspectiveness (i.e., tendancy to devote diffuse attention to thoughts and feelings about the self) (7) or neuroticism (i.e., emotionally unstable, vulnerable to stress, and self-conscious) (8) are particularly likely to experience and report unexplained physical symptoms.
Somatization as Reinforced Behavior
Somatization may be viewed as behavior modeled or reinforced by the patient's environment (9). This perspective prompts exploration for a history of similar symptoms in the patient or a close contact and encourages a search for evidence of social benefit associated with the patient's current symptoms.
Case Example
A 20-year-old woman was evaluated in the office for back pain. The physical examination was unimpressive, and an extensive workup was unrevealing. Discussions with the family disclosed that the patient's father was about to lose his disability income and that financial hardship was expected. Environmental reinforcements related to possibly becoming eligible for disability, thereby ameliorating the family's anticipated financial crisis, probably contributed to the continuation of this patient's symptoms.
Somatization and the Life Story
Somatization may be viewed as a maladaptive but understandable expression of, or response to, difficulties originating in early life experiences. This perspective is at least as old as the concept of “hysterical conversion,” introduced in 1795 by John Ferrier and elaborated upon by Freud and Breuer in the late 19th century (10), and its validity is supported by abundant evidence that persons with histories of childhood abuse have higher rates of unexplained physical symptoms and medical services utilization (11,12). Although particular formulations are difficult to prove in individual cases, they may help clinicians comprehend and manage illness behavior that is otherwise irritating and baffling. For example, patients who suffer parental abuse and neglect may carry into adulthood potent mixtures of hostility and dependency that are activated in relationships with health care practitioners. Such patients may develop physical symptoms without diagnosable disease and pursue unrevealing medical evaluations. Sometimes hostile and demanding, they may demean the competence and the commitment of their health care practitioners, even as they crave medical attention and insist on even more care. Such behaviors may be seen as expressions of angry disappointment with their earliest caretakers, who did not adequately meet their dependency needs, now displaced onto the practitioner. Other patients may have childhood memories of experiencing attention and caring only when they were ill, or they may have come from families or cultures in which it was customary to express emotional distress as physical symptoms. Such formulations may help clinicians respond to such patients without anger and permit the development of a constructive doctor–patient relationship. Other formulations of this type are discussed elsewhere (13).
Reaching a Working Formulation and Making a Diagnosis
Thus the development of a working formulation requires consideration of the relative merits of the four distinct explanatory points of view in a particular case. Once the clinician has determined that the unexplained symptoms are not because of a previously undiagnosed medical disorder, there are four fundamental questions:
As shown later, the working formulation often carries specific therapeutic implications.
Somatizing patients may fall into defined diagnostic groups (Table 21.1). The diagnostic classification of somatization is presently under review, and there are proposals
P.295
for radical revision (14). Despite these controversies, there is agreement that unexplained somatic symptoms account for a substantial proportion of both primary care and specialist visits and that the formal somatoform disorders (e.g., conversion disorder, somatization disorder, hypochondriasis) and factitious disorders account for only a small proportion of these cases (14). Many more patients have incomplete forms of these conditions (e.g., somatoform disorder not otherwise specified; undifferentiated somatoform disorder), adjustment disorders with anxiety or depression partly manifested by somatic symptoms, or actual medical conditions whose manifestations are influenced by psychosocial factors (see Psychological Factors Affecting Medical Conditions section).
|
TABLE 21.1 Psychiatric Disorders Associated with Somatization |
|
|
This chapter reviews adjustment disorders, psychological factors affecting medical conditions, the primary somatoform disorders, and disorders in which symptom production is deliberate. Mood disorders (Chapter 24), anxiety disorders (Chapter 22), schizophrenia (Chapter 25), and personality disorders (Chapter 23) are discussed in detail elsewhere in this book.
Adjustment Disorders
Description
Adjustment disorders are reactive emotional states resulting from difficulty meeting the demands of life. Patients feel overwhelmed by illness, marital discord, or other problems and become demoralized. While adjustment disorders are classified according to the patient's predominant psychological symptomatology (e.g., depression, anxiety), sometimes the patient's most prominent complaints are somatic symptoms. It is in these cases that patients with adjustment disorders are most likely to present to their general health providers. This is because (1) somatic complaints legitimize a visit to the doctor and (2) emotional distress precipitated by stressful experiences can amplify bodily symptoms and lead patients to become convinced that they are seriously ill. When emotional and somatic symptoms arise in response to psychosocial problems, a diagnosis of adjustment disorder should be considered (see Table 24.1 in Chapter 24).
Case Example
A shy 26-year-old parochial school teacher was evaluated for dizziness, abdominal cramps, nausea, excessive urination, and a sensation of fullness in the bladder. When physical examination and laboratory tests revealed no physiologic disturbance, a more detailed history was taken. It showed that the patient's symptoms began shortly after a confrontation with his school principal over his attempt to organize a teacher's union and his criticism of school policies. (Diagnosis: adjustment disorder with anxiety and physical symptoms.)
Patients such as this one are often unaware of the relationship between their psychological distress and somatic symptoms.
As illustrated in the following example, diagnosis may be difficult when the symptoms precipitated by psychosocial stress resemble those of a patient's established disease process.
Case Example
A 54-year-old widow recovering from a myocardial infarction complained to her primary care practitioner of fatigue, breathlessness, and pleuritic chest pain unrelated to exertion. Her physical examination and electrocardiographic findings were unchanged. Questioning revealed that the patient was forced to leave her job after her heart attack and was barely able to afford necessary medications. She tearfully revealed that, although her son had offered to help pay for her medications, her daughter-in-law hinted that they could not really afford to help. This proud and formerly self-sufficient woman, who was initially reluctant to accept any help, now felt even more vulnerable and inadequate, and she acknowledged that the periodic symptoms in her chest invariably occurred while she was thinking about these difficulties. (Diagnosis: adjustment disorder with mixed emotional features and physical symptoms.)
In this case, emotional distress produced symptoms suggesting cardiac disease. The correct diagnosis was made when the relevant history was elicited.
P.296
Management
Three strategies are important in evaluating patients who may have adjustment disorders:
The identification of a psychosocial basis for patients’ somatic complaints is often sufficient to allow them to marshal their own resources for coping (17). When these measures fail, the patient may need goal-focused short-term counseling (see Chapter 20). In selected cases, short-term prescription of anxiolytic or hypnotic medications may be helpful.
There have been only a few reports of outcomes of minor mood disturbances managed by generalists (17, 18, 19). From these studies, the following tentative conclusions can be stated:
Several practical considerations regarding longitudinal management are suggested by these findings:
Psychological Factors Affecting Medical Conditions
Description
Psychological factors can exacerbate somatic symptoms caused by a concurrent physical disorder. The resulting symptoms are sometimes called psychophysiologic. Table 21.2 lists the most common conditions in which such symptoms may occur. When the features listed in Table 21.3 are present, the diagnosis from the Diagnostic and
P.297
Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), is Psychological Factors Affecting Medical Condition.
|
TABLE 21.2 Common Conditions in Which Psychophysiologic Symptoms Are Important |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Most of the conditions listed in Table 21.2 may occur with or without a significant psychological component; detailed descriptions of most of these conditions are found elsewhere in this book, as indicated in the table. For a patient's symptoms to be interpreted as psychophysiologic, they should bear a temporal relationship to a stressful life situation and should subside when the stressful situation abates.
|
TABLE 21.3 Diagnostic Criteria for Psychological Factors Affecting Physical Condition |
||
|
Conversion symptoms (see Conversion Disorder section) are differentiated from psychophysiologic symptoms by the absence of a pathophysiologic condition in the former. Psychophysiologic problems are closely related to adjustment disorders, but they are distinguishable from them in that the somatic symptoms are caused by a recognized pathophysiologic condition and the same symptoms may occur in the absence of psychosocial stressors. This diagnosis is also used when psychological factors interfere with the treatment of a general medical condition (e.g., when strong denial of illness interferes with adherence to medication regimens).
Management
When initiation or exacerbation of a physical condition is related to environmental stressors, management is the same as that described for adjustment disorder.
P.298
Somatoform Disorders
As a group, the somatoform disorders are characterized by the occurrence of physical symptoms that lack an organic basis and are linked, by positive evidence or strong presumption, to psychological factors or conflicts. They may be acute or chronic, mild or severely disabling. Because patients with these disorders believe themselves to be physically ill, they are treated primarily by nonpsychiatrists and generally do not accept psychiatric referral. In addition to the management strategies described here, the strategies for managing abnormal illness behavior, described in Chapter 20, usually are helpful.
Somatization Disorder
Description
The best-studied disorder in this group is somatization disorder, formerly known as hysteria or Briquet syndrome. This is a chronic disorder beginning before 30 years of age in which the patient seeks treatment for multiple, widely distributed symptoms lacking any known pathologic basis or pathophysiologic mechanism. To meet DSM-IV criteria for this disorder, the patient must have a history of at least eight such symptoms, drawn from the four symptom subgroups listed in Table 21.4: Pain symptoms (at least four), gastrointestinal (GI) symptoms (two or more), sexual symptoms (at least one), and pseudoneurologic symptoms (at least one). Accurate diagnosis often requires review of old records and careful history-taking to determine that a sufficient number of unexplained symptoms have been presented for evaluation and treatment or have caused the patient to take over-the-counter (OTC) remedies or alter his or her lifestyle. Seven symptoms are especially useful in screening: shortness of breath without exertion, dysmenorrhea, burning sensations in sexual organs, difficulty swallowing (lump in throat), amnesia, vomiting, and pain in extremities. The presence of three of these symptoms without adequate physical explanation identifies somatization disorder with a sensitivity of 87% and specificity of 95% (20). Symptoms are often described in dramatic and colorful terms, but details tend to be vague and contradictory.
|
TABLE 21.4 Diagnostic Criteria for Somatization Disorder |
||
|
Somatization disorder occurs in 0.2% to 2.0% of women in the general population, but it is much more common among women seen in clinical settings (21). It is rare in men. Histrionic personality traits may be present. Somatization disorder occurs in 10% to 20% of female first-degree relatives of women with somatization disorder; alcoholism and antisocial personality disorder occur frequently among their male relatives.
Common complications include substance abuse and iatrogenic illness. One classic study found that women with hysteria undergo more than three times as many operations as control women and lose, by weight, more than three times the mass of organs (22).
The disorder is chronic. In a retrospective study of 49 patients, almost 70% of women were still symptomatic 15 years after diagnosis (23). However, the mortality rate of women with somatization disorder is the same as that of normal women (24), and the likelihood of developing another medical or psychiatric disorder explaining the symptoms is only 10% in long-term followup (25).
P.299
Case Example
A 43-year-old married woman was referred for psychiatric evaluation by her internist who, noting her presentation with ill-defined symptoms, was requesting help with management. She complained of generalized muscle aching and periodic sensations throughout her body described as “how you feel when someone scratches his fingers on a blackboard.” She also complained of skin lesions on her back and stated that she was hypothyroid and suffered from a chronic urinary tract infection. Her history included tonsillectomy, groin lymph node biopsy (twice), hysterectomy, bladder suspension (twice), rectocele repair, removal of abdominal adhesions, multiple cystoscopies, appendectomy, and removal of a tongue papilloma. The patient stated she had Ménière disease and episodes of sudden shortness of breath. She also carried a diagnosis of fibrositis, for which she had taken steroids in the past, and restless legs syndrome. She had stopped having sexual intercourse with her husband because of “pain that 10 gynecologists could not cure.” Her current medicines included a benzodiazepine, a nonsteroidal anti-inflammatory agent, and a belladonna alkaloid. She mentioned that she had always been ill and that she hated men. Her psychosocial history included marriage to an alcoholic who abused her and a positive family history of suicide. In presenting her symptoms, the patient was extremely vague and interjected facts about her emotional life with an inappropriate laugh. She believed that her symptoms were caused by food allergy. She had stopped eating and at the time of her initial visit to her internist had ingested only distilled water for 4 days. Physical examination and laboratory test results were normal.
Management
Because these patients adhere firmly to the idea that they are physically ill, they usually do not accept psychiatric referral, and their treatment lies largely in the hands of nonpsychiatrists. Guidelines for management include the following:
The usefulness of measures such as these in the management of somatization disorder has been demonstrated in a randomized, controlled study (27).
P.300
Undifferentiated Somatoform Disorder and Multisomatoform Disorder
Undifferentiated somatoform disorder is a residual category designed to accommodate patients who do not fully meet criteria for somatization disorder (Table 21.5). Symptoms must be present for at least 6 months for the diagnosis to be made. There need be no identifiable precipitant. Although the disorder has not been well studied, it is believed to be much more common than somatization disorder. Its prognosis and clinical course are unknown.
|
TABLE 21.5 Diagnostic Criteria for Undifferentiated Somatoform Disorder |
||
|
Multisomatoform disorder is a term that does not appear in DSM-IV. It has been proposed as an alternative to “undifferentiated somatoform disorder” for patients with a 2-year history of apparent somatoform symptoms and at least three current somatoform symptoms, reported from a 15-symptom checklist (28). Of 1,000 participants in the Primary Care Evaluation of Mental Disorders (PRIME-MD) (29) study, 82 (8.2%) met criteria for this condition. These patients had significantly greater numbers of disability days and doctor visits as well as impairments in health-related quality of life and were far more likely than patients with other psychiatric conditions to be judged “difficult” by their physicians.
Although there are no studies of treatment for these specific disorders, there is evidence that techniques useful in full-fledged somatization disorder (see Somatization Disorder, Management) are helpful for long-term somatizing patients who do not meet all of the diagnostic criteria for somatization disorder (30).
|
TABLE 21.6 Diagnostic Criteria for Conversion Disorder |
||
|
Conversion Disorder
Description
Conversion disorder is a disorder in which an unexplained loss or alteration of body functioning develops in the presence of evidence that the symptoms solve or express a psychological conflict or need (Table 21.6). The symptoms often simulate neurologic disease but conform to the patient's notion of body function rather than to the rules of neuroanatomy, and medical evaluation yields no evidence of diagnosable disease. Amnesia, aphonia, blindness, paralysis, numbness, and seizures are among the most common conversion symptoms. The disorder probably occurs more often in women than in men, and it usually begins in adolescence or early adulthood. Patients may have histrionic or dependent personalities and may exhibit remarkable serenity (“la belle indifference”) in the face of their impairments.
Conversion disorder is unique among DSM-IV somatoform disorders in that the definition not only describes the diagnostic criteria but also proposes psychological mechanisms as explanations. A mechanism called secondary gain is invoked when unexplained symptoms allow the patient to avoid onerous tasks or undesirable duties (see Somatization as Reinforced Behavior).
Case Example
A 15-year-old girl with a history of migraine headache and transient visual field cuts was evaluated for a new visual field cut that had developed without headache over the previous 24 hours. On examination, the visual defect was found to “split the macula.”
P.301
At the time of psychiatric interview she revealed that she expected her visual problems to prevent her from obtaining a driver's license when she turned 16. She went on to say that she was afraid to drive, that no other woman in her family drove, and that she would be called upon by everyone to provide transportation. She was referred to a pediatric neurology service, where she received physical therapy and daily psychotherapy. Her field defect resolved.
A second mechanism, primary gain, is invoked when conversion symptoms appear to resolve an internal conflict created by a feeling, impulse, or wish that the individual finds frightening or morally unacceptable.
Case Example
A 50-year-old man was admitted to the hospital because of amnesia. He spoke normally and was otherwise neurologically intact, although he could not remember his name or any other details of personal history. After about 24 hours he began speaking freely about anger related to the recent dissolution of his marriage. Particularly upsetting had been news that his boss was dating his wife. Immediately before the development of amnesia he had thought that he might be provoked to violence if he discovered them together. His amnesia completely resolved in 2 days, and he was discharged from the hospital. He briefly participated in outpatient psychotherapy. The working formulation was that the amnesia had served to remove unacceptable violent intentions from his awareness and to protect him from acting on them.
Acute conversion symptoms have a good prognosis for recovery, especially if the patient has no other psychiatric disorder.
Management
Guidelines for the treatment of patients with conversion disorder include the following:
Hypochondriasis
Description
Hypochondriacal concerns that are relieved by evaluation, explanation, and reassurance are common in medical practice. Hypochondriasis, however, is a chronic disorder in which unrealistic interpretation of physical symptoms leads the patient to fear the presence of a serious illness in the face of repeated reassurances based on adequate medical evaluation (Table 21.7). Onset is usually in the third decade but may occur later. Both sexes are equally affected. Obsessive-compulsive personality traits are often observed. Anxiety, depression, drug dependence, and iatrogenic disease are common complications. The disorder tends to be chronic, with waxing and waning intensity. Symptomatic exacerbations occur in response to psychosocial stresses and to stimuli that provoke bodily preoccupation and fear of disease.
|
TABLE 21.7 Diagnostic Criteria for Hypochondriasis |
|||
|
Case Example
A 30-year-old accountant had always been self-conscious about his physical appearance, a concern that he attempted to allay by weight lifting. After his father died of a heart attack, he became concerned that he might have heart disease and was fearful about the implication of insignificant chest pains. He also worried about his blood pressure, which was transiently elevated at the time of his yearly physical examinations. His most recent examination revealed insignificant liver enzyme elevations, a finding over which he fretted for weeks. Despite these concerns, he rarely missed a day of work. He was not sure that he did not have a serious disease but thought he had best trust his health care provider.
P.302
Management
Because patients with hypochondriasis believe that they are physically ill, they often refuse psychiatric treatment. Guidelines for management by generalists are similar to those for other chronic somatoform disorders and include the following:
Pain Disorder
Description
Somatoform pain disorder is a chronic disorder characterized by unexplained or amplified complaints of pain (Table 21.8). It usually has its onset in the fourth or fifth decade and is associated with marked functional disability. The diagnosis is most useful when psychological factors can be linked to the onset and maintenance of pain. A typical scenario begins with lower back pain, which often develops on the job and is initially diagnosed as a sprain. The patient may see his or her primary care practitioner and attempt
P.303
to return to work. Soon thereafter the pain recurs, sometimes after apparent reinjury. Specialty consultations (e.g., orthopedic, neurosurgical) ensue. Conservative treatments (e.g., physical therapy) are ineffective. Surgery may be performed, perhaps with transient benefit, but soon there is a resurgence of symptoms described as worse than ever. After 6 to 12 months of illness the patient is out of work, socially isolated, physically inactive, dependent on narcotic analgesics, angry, and demoralized. He or she may believe that health professionals and family members do not regard the pain as real.
|
TABLE 21.8 Diagnostic Criteria for Pain Disorder |
||
|
Management
Treatment of somatoform pain disorder is similar to the management of other somatoform disorders:
Body Dysmorphic Disorder
Description
Body dysmorphic disorder is a disorder characterized by an excessive or completely unfounded preoccupation with a defect in personal appearance (Table 21.9). The prevalence of the disorder is unknown. Onset typically occurs between adolescence and age 30 years. Perceived facial imperfections, such as the shape of the nose or jaw, are the most common sources of concern.
|
TABLE 21.9 Diagnostic Criteria for Body Dysmorphic Disorder |
||
|
Case Example
A 60-year-old man entered into psychiatric treatment for chronic depression. He reported long-standing attitudes and patterns of behavior suggesting obsessionality and extreme self-consciousness. He also reported a preoccupation beginning in adolescence with the shape of his jaw. He had undergone elaborate surgical treatment for this but continued to feel that other people were put off by his appearance, a belief contributing to his social discomfort. The examining psychiatrist found nothing remarkable about the appearance of his face. The patient's preoccupation with this perceived defect was partially ameliorated by antidepressant treatment, but he continued to regard himself as misshapen.
P.304
Management
Little is known about the treatment and prognosis of the disorder. Some authors believe it should be regarded as a symptom, not as a distinct condition. Generally, patients should be discouraged from pursuing surgical solutions, especially when their concerns are entirely unfounded. Otherwise, many of the management guidelines described earlier for other chronic somatoform disorders are applicable. In particular, it is useful to review the four explanatory perspectives for factors promoting the development and maintenance of the symptoms and to treat any specific etiologic factor identified: an associated major psychiatric illness (usually major depression), personality types predisposing to the disorder (especially obsessive-compulsive and avoidant types—see Chapter 23), behavioral models for these concerns (e.g., parents who were dissatisfied with similar physical attributes in themselves), and aspects of the life story that make the symptoms empathically understandable (e.g., early experiences with critical parents leading the patient to feel unwanted or unacceptable).
Disorders with Voluntary Symptom Production
The fundamental feature of disorders with voluntary symptom production is the deliberate simulation of physical symptoms. This characteristic distinguishes patients with these disorders from those with chronic somatoform disorders, described earlier, in which symptom genesis is not deliberate.
|
TABLE 21.10 Diagnostic Criteria for Factitious Disorder with Physical Symptoms |
||
|
Factitious Disorder with Physical Symptoms
Description
Factitious illness is characterized by the deliberate simulation of physical symptoms for the sole purpose of assuming the sick role (35). When this behavior is chronic and leads to multiple hospitalizations, it is known as chronic factitious disorder with physical symptoms (Table 21.10) or Munchhausen syndrome. When there is deliberate simulation of a psychiatric syndrome, it is designated as Factitious Disorder with Psychological Symptoms.
Patients may report invented symptoms (e.g., severe right lower quadrant abdominal pain), or they may deliberately produce physical signs by heating thermometers, tying tourniquets around their legs, or ingesting anticoagulant drugs. The history may be dramatic but vague in medically relevant detail. Onset is usually in early adulthood, often shortly after hospitalization for a bona fide physical illness. Job stability, family life, and other interpersonal relationships suffer profoundly as a result of multiple lengthy hospitalizations.
Management
The main goals of management are to prevent unnecessary hospitalizations and to avoid invasive procedures. The management of the hospitalized patient may be facilitated by early psychiatric consultation to assist in diagnosis, determine whether other treatable psychiatric disorders are present, help plan tactful confrontation of the patient with the diagnosis, and attempt to persuade the patient to accept psychiatric hospitalization.
Malingering
Description
Malingering is the deliberate simulation of physical (or psychological) symptoms to achieve a specific benefit. It
P.305
is an important and common problem in settings where sickness is rewarded with certain benefits (e.g., avoidance of military service or court appearances, financial compensation for injuries). Malingering comprises three types (see Ford, athttp://www.hopkinsbayview.org/PAMreferences):
The diagnosis of malingering should be suspected whenever symptoms or disabilities greatly exceeding objective disease are accompanied by obvious social or financial benefit. Other observations suggesting the diagnosis include inconsistency of symptoms (e.g., a blind person detected reading), unusually vague or markedly exaggerated reports of symptoms, and the expression of indignant anger in response to gentle confrontation.
Malingering must be distinguished from factitious disorders, in which the patient has no goal aside from achieving patienthood, and from conversion disorders, in which symptom production is not conscious or intentional.
Management
The goal of management is to persuade malingering patients to give up their symptoms. Patients should gradually and tactfully be made aware that malingering is suspected, and the gratifications associated with the sick role should be removed. Reports of symptoms should be given minimal attention. If psychiatric disorders are thought to underlie or complicate apparent malingering, psychiatric consultation should be obtained.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.