in the last video we talked about somatic symptom disorder which is the prototypical disorder featuring medically unexplained symptoms in this video we'll take a whirlwind tour through the other somatoform disorders including illness anxiety disorder conversion disorder factitious disorder and malingering let's start with illness anxiety disorder which was formerly called hypochondriasis although this term has fallen out of favor while illness anxiety disorder has historically been lumped together with somatoform disorders the emerging consensus now is that this more accurately belongs under the banner of ocd spectrum disorders so if you haven't watched the video on ocd yet make sure to do that first the link is in the description below so what exactly is illness anxiety disorder at its core illness anxiety disorder involves an obsessional preoccupation that one has a medical disease often something of a very serious nature like cancer unlike in somatic symptom disorder where the patient's distress is about the symptoms themselves in illness anxiety disorder the patient's distress is instead about the belief that they have a disease with symptoms generally being perceived as merely the manifestations of this disease such as thinking that a headache must be a symptom of brain cancer it's a small nuance but it's an important one for truly understanding both of these conditions luckily the key words for each are embedded into their names somatic symptom disorder is about the symptoms while illness anxiety disorder is about the illness or disease the patient's belief that they have a disease leads them to spend lots of time and energy in compulsive health-related behaviors such as researching the disease online or scanning themselves for signs of the disease like repeatedly checking for suspicious lumps or taking their own vital signs while some patients will avoid seeking medical care out of fear for what they'll find other patients end up frequently going to the hospital or clinic for evaluation their health care provider will proceed to order a lot of medical tests but because there's nothing physically wrong everything will come back negative while this would be a reassuring for most people someone with illness anxiety disorder will not only continue to believe that they have a medical disease but will actually become more dissatisfied and anxious in response to the negative findings this is because just like in ocd no amount of reassurance will lead to a feeling of knowing that they don't have a disease and their obsessive thoughts about having a disease will persist no matter how much evidence is presented to the contrary with patients saying things like i don't care what all the doctors in labs in imaging reports say i know that i have cancer more than just being distressing this persistent belief can severely disrupt the patient's life and lead to significant dysfunction for example if a patient truly believes that they are seriously ill they may resign from work or stop seeing family and friends furthermore the behavior related to this belief can potentially put them at risk of medical harm like side effects from unnecessary medications scars from exploratory surgeries or high doses of radiation from repeated x-rays looking at this pattern we can see why illness anxiety disorder is best thought of as an ocd spectrum disorder it features the same loop between an obsessive thought in this case a belief that one has a medical disease and compulsive behaviors such as checking for signs of the disease over and over that directly lead to distress and dysfunction rather than memorizing the diagnostic criteria the highest yield approach when diagnosing illness anxiety disorder is simply to look for this pattern illness anxiety disorder appears to be relatively uncommon with the prevalence of around 0.5 of the general population like other obsessive compulsive disorders illness anxiety disorder most commonly begins in early adulthood and is found equally among men and women studies on the prognosis of illness anxiety disorder are few and far between but the data that do exist suggest that it is similar to other ocd spectrum disorders and that most cases are chronic and enduring without treatment with most patients continuing to have symptoms years or even decades into the future treatment for illness anxiety disorder consists of cbt as a first-line option as it is very effective with large reductions in both distress and disability use of serotonin boosting medications appears to be helpful as well however both forms of treatment are limited by low rates of engagement as the patient needs to believe that there is a psychological problem at the root of their distress in order to truly benefit nevertheless patients who do engage in treatment appear to have much better outcomes so it's definitely worth trying to encourage patients to engage in treatment as much as possible the next stop on our tour of somatoform disorders is conversion disorder which also increasingly goes by the name functional neurologic disorder you can remember the core features of this diagnosis by thinking of it as cant version disorder which should help you remember that it involves a clinically unexplained medical abnormality specifically involving the nervous system that is sometimes but not always brought on by stressful trigger the word can't will also help you remember that these patients aren't faking it they genuinely can't do the things they say they can't even in the absence of objective pathology let's look at each part of this definition in more detail first the clinically unexplained medical abnormalities can be either subjectively reported symptoms such as blindness or loss of sensation or they can be objectively observed signs such as slurred speech or tremors in addition conversion disorder can involve either the absence of function as in muscle weakness or the presence of dysfunction as in recurrent seizure-like activity importantly these abnormalities all involve functions of the nervous system specifically so a diagnosis of conversion disorder would not be appropriate for a patient presenting with abdominal pain or chest discomfort given that most neurologic deficits involve areas that people have voluntary control over it's easy to conclude that people with conversion disorder are either faking it or just not trying hard enough however the can't of can't virgin disorder will remind us that despite how it may feel to an outside observer people with conversion disorder are not faking their disability historically the dsm required that there be a recent stressor in the patient's life with the stressor being the thing that is converted into the neurologic abnormality such as a patient developing leg weakness and becoming unable to walk after their parents are killed in a car crash however only about 50 of people with conversion disorder have a recent stressor so it's no longer required for a diagnosis of this disorder even if it can still be an important diagnostic clue in some cases while exact statistics on conversion disorder in the general population are lacking we do know that up to a third of all new patients seen in neurology clinics likely have a functional neurologic disorder making it one of the most common reasons that people see a neurologist the disorder most often affects adolescents and young adults although cases in both children and elderly have been reported there is a large gender gap in conversion disorder with studies estimating that between three and ten times more women are diagnosed with this condition than men conversion disorder actually has a pretty decent prognosis for the neurologic deficit itself over 90 percent of cases resolve within a few days or weeks and 75 percent of people never have another episode with only around a quarter of patients experiencing recurrent unexplained neurologic deficits however the prognosis is less good for the patient more broadly as many continue to struggle with other symptoms like depression anxiety and interpersonal problems even after the neurologic deficit has resolved conversion disorder requires a fundamentally different treatment approach than other somatoform conditions like somatic symptom disorder or illness anxiety disorder as typical treatments like cbt and antidepressants are not effective here instead treatment should consist of educating the patient and their family about the nature of their disorder when doing so it's important not to confront the patient or in any way imply that they are lying or not trying hard enough as this is not only inaccurate but counterproductive as well instead emphasize that a lack of objective medical lab or imaging results is good news and be optimistic that their condition will improve with time for patients with motor deficits physical therapy has been shown to improve functional ability even in the absence of objective neurologic pathology before we close the book on conversion disorder let's see if we can better understand it by viewing it through a different lens just like illness anxiety disorder is actually an ocd spectrum disorder in disguise some researchers believe that conversion disorder is best thought of as a dissociative disorder in disguise if you haven't watched the video on dissociative disorders yet make sure to do that first as this discussion won't make much sense without it support for the idea that conversion disorder is actually dissociative disorder comes in a few places first conversion disorders frequently co-occur alongside dissociative disorders with comorbidity between 30 and 50 in some studies in addition conversion disorder and dissociative disorders both share a common epidemiology prognosis and treatment response with the same age of onset in adolescence in young adulthood the same 10 to 1 gender ratio the same good prognosis for the neurologic deficit that you see in dissociative amnesia and in roughly the same amount of time and the same lack of response to conventional treatments like psychotherapy and medications mechanistically conversion disorder is believed to share a common pathophysiology with dissociation with the key abnormality being that there is a split between the patient's experience and their awareness of their experience which is most notable in things like automaticity where the patient engages in a behavior but is not aware of it other shared traits including a high degree of suggestibility a tendency towards hypnotizability and frequent histories of early life trauma all support this link as well taken together these patterns suggest that conversion disorder is best understood through the lens of dissociative disorders and looking at it this way will help you understand both of these often confusing diagnoses better and with that we arrive at the last stop on our tour of somatoform disorders let's finish by talking about factitious disorder and malingering unlike all the somatoform disorders we've talked about so far in which the symptoms and dysfunction are genuinely experienced by the patient in these conditions the medically unexplained symptoms are intentionally feigned or exaggerated this begs the obvious question why would someone fake being sick the answer to this question is the basis for the distinction between factitious disorder and malingering in factitious disorder which is formerly known as munchausen syndrome although this term has largely fallen out of favor the goal of fading illness is primary gain which refers to all the intangible benefits associated with being sick such as sympathy and attention for example someone with factitious disorder may feign having severe abdominal pain in order to be admitted to the hospital and receive around-the-clock care from doctors nurses and other providers in some cases people with factitious disorder will even permit significant disfigurement and disability such as undergoing multiple invasive surgeries because they desire to remain in the sick role over and above preserving their own health in extreme cases people with factitious disorder may even intentionally harm themselves in order to provide evidence that they are truly sick with cases being reported of people having injected their own feces into their bloodstream for the purposes of inducing an infection for patients with factitious disorder the need to receive attention through the sick role has become so acute that they will go to extreme lengths to maintain it while all those examples involve the patient putting themselves in the sick role for primary gain known formally as factitious disorder imposed on self there are cases in which the patient puts their child or other dependent person in the sick role which is known as factitious disorder imposed on another or formerly munchausen syndrome by proxy while the methods are different the goal is the same to receive the sympathy and attention that accompanies the sick rule in some cases the parent may even actively harm their child in order to keep them in the sick role which is one of the deadliest forms of child abuse that exists and necessitates immediate steps to protect the child a definitive diagnosis of factitious disorder requires clear evidence that the patient is intentionally fabricating their symptoms however this cannot always be found so cases of factitious disorder often end up suspected rather than confirmed you can use the mnemonic fractitious to remember some key patterns suggestive of this disorder including repeat failure of treatments that are generally effective in most cases recurrent presentations for medical evaluation especially if it involves many different hospitals and clinics atypical signs and symptoms that don't match the known pathology of the disorder clingy or contentious interactions where the patient appears to enjoy being the sick role or becomes hostile when discussing things like discharging from the hospital and finally when the patient appears to have a knowledge of their reported illness that goes far beyond what's typical for most patients all of these patterns are just clues however so don't be misled into thinking that you have definitively diagnosed factitious disorder even in cases where all of these patterns are present because definitive diagnosis is often elusive it can be difficult to find clear data on factitious disorder nevertheless some patterns have emerged factitious disorder is rare with a prevalence of only 0.1 percent of the population however in acute settings like the hospital the rate may be 10-fold higher with one percent of patients showing patterns suggestive of the disorder people with factitious disorder are typically in their thirties and are more often female with a gender ratio of two to one interestingly more than fifty percent of patients with factitious disorder themselves work in medical field with nursing being the most common occupation many patients with factitious disorder also had a family member with a chronic medical condition growing up both of these suggest that exposure to the dynamics of the sick role play a big part in the development of this disorder factitious disorder has a relatively poor prognosis in large part because people with this disorder tend to have many other mental disorders as well with personality trauma related mood and anxiety disorders being common the rate of suicidal thoughts and attempts is high as well at around 15 percent of patients placing it on par with the mood disorders treatment for factitious disorder is difficult as neither medications nor psychotherapy have been shown to be effective in addition it is unclear whether confronting the patient about factitious behavior is helpful or harmful as studies have shown no difference between confrontational and non-confrontational approaches nevertheless it seems reasonable to try and work with patients who have factitious disorder from the perspective of trying to create a safe and therapeutic alliance while acknowledging that allowing the patient to continue in these patterns is likely to result in harm in contrast to factitious disorder where the main draw is primary gain or all the benefits intrinsic to the sick role in malingering the goal is secondary gain or an extrinsic benefit that someone is getting from being sick including disability payments an excuse from work or military service a lighter sentence in a criminal case financial compensation for a fake injury access to drugs like painkillers or admission to a hospital with its associated food and shelter like with factitious disorder diagnosing malignant can be hard as a definitive diagnosis requires clear evidence of fabrication however there are a few key clues that can help alert you to the presence of malingering you can use the mnemonic sham which stands for clear evidence of secondary gain holes or inconsistencies in the patient's story a history of antisocial traits or behaviors in a pattern of missing medical appointments or treatments that do not directly benefit them just like the fractitious disorder mnemonic even if all these clues are there that is not enough to definitively diagnose malingering though it can still be strongly suggestive of it unlike factitious disorder malingering is not considered to be a mental disorder as people will exaggerate fabricate or lie for various reasons many of which are not necessarily related to mental health for this reason there are no clear patterns of epidemiology or prognosis associated with malingering and there is no treatment for it per se however it can still be helpful to have a clinical strategy when working with a patient that you suspect of malingering when talking with the patient the best approach is to ask open-ended questions that cannot be answered with a simple yes or no which avoids providing the patient with a road map of which symptoms are important and which are not most importantly pay attention to your own emotions it's easy to get frustrated or even angry when you feel that a patient is manipulating or lying to you and a common reaction is to try and punish the patient or kick them out of the hospital however ultimately malingering is a way for patients who have not been able to meet their needs through other means to communicate that they need help so take a moment to gather your thoughts and process your emotions then try to work out whether there might be more productive ways of helping the patient meet their needs for example if you're working with a homeless patient who's malingering in order to be admitted to the hospital and get a roof over their head you may be able to connect them with social work resources housing and other forms of support that will likely be more helpful to them in the long term so that's factitious disorder and malingering while we have grouped them together based on the fact that they both involve intentional feigning of illness they really are two separate conditions that should be considered independently so let's introduce a mnemonic to distinguish between them one key difference has to do with the patient's pattern of behavior after their need has been met focus on the first three letters of each word to remind yourself that someone who is malingering always leaves once they get what they want because there's no longer a reason for them to seek medical care while someone with factitious disorder always comes back for more as their primary goal is the medical care itself okay we're done we've covered all the major conditions that have medically unexplained symptoms as a core feature this is a confusing topic to be sure with a lot of gray areas and even a few disorders in disguise the best way to make sure you understand it is to test your knowledge with some practice questions which you can do using my book memorable psychiatry you may also 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