‘Caring Rather T han C uring,’ the Simulated Syndromes

1. ‘Caring Rather Than Curing,’ the Simulated Syndromes Jonny Gerkin, MD Assistant Professor UNC Department of Psychiatry

2. What are we really talking about? • Somatoform Disorders, Factitious Disorders and Malingering

3. SOME VOCABULARY • Unconscious • Conscious • Primary gain • Secondary gain • Sick role • Somatization • Simulation Prepare to be bored!.. briefly

4. Unconscious • The division of the mind in psychoanalytic theory containing elements of psychic makeup, such as memories or repressed desires, that are not subject to conscious perception or control but that often affect conscious thoughts and behavior. • Conscious • In psychoanalysis, the component of waking awareness perceptible by a person at any given instant; consciousness.

5. Primary gain • The direct alleviation of anxiety by a defense mechanism; the relief from emotional conflict or tension provided by neurotic symptoms or illness. The "gain" may not be particularly evident to an outside observer. • Secondary gain • The external advantage derived from an illness, such as rest, gifts, personal attention, release from responsibility, and disability benefits. If he/she is deliberately exaggerating symptoms for personal gain, then he/she is malingering. However, secondary gain may simply be an unconscious psychological component of symptoms and other personalities.

6. Sick role • Aterm used in medical sociology concerning the social aspects of falling ill and the privileges and obligations that accompany it…being sick means that the sufferer enters a role of 'sanctioned deviance.‘ i.e., they get to skip work! Sick Role, not to be confused with Rollin’

7. Somatization • A process describe as the tendency of certain patients to experience and communicate psychological and interpersonal problems in the form of somatic distress and medically unexplained (or out of proportion) symptoms for which they seek medical help. • It is vital for medical practitioners to recognize somatization as a MASKED PRESENTATION OF PSYCHIATRIC ILLNESS. Somatization ≠ Somatoform D/O

8. Simulation • In this context we are referring to the production of symptoms. Whether it is conscious or unconscious, volitional or non-volitional, is secondary.

9. All of the above have some elements of SIMULATION and DECEPTION & elements of primary and secondary gain - each existing on a continuum & varying over time and context.

10. Somatoform disorders include: • Somatization Disorder • Undifferentiated Somatoform Disorder • Conversion Disorder • Pain Disorder • Hypochondriasis • Body Dysmorphic Disorder • Somatoform Disorder NOS Common feature = unexplained physical symptom not intentionally produced

11. There are major difficulties in the clinical application of somatoform disorders… • Spinal Cord Astrocytoma Mistaken for Conversion Disorder… • Catatonia mistaken for Conversion… • ‘a diagnosis of conversion disorder mustremain a provisional hypothesis that has to be periodicallyreevaluated.’ Excluding a medical cause for symptoms is problematic

12. Clinical Vignette: The medical service requests a consult, the pt is demanding unnecessary trx, pain out of proportion. • 28 yo SWF c/o pelvic pain, N and V requesting IV vancomycin for her “pelvic infection.” She vaguely describes some vaginal discharge. • She is afebrile with stable vital signs otherwise. • H/o unilateral oophorectomy d/t pain of ovarian cyst and endometriosis 4 months prior. Post-op course was “complicated” by soft tissue infection requiring multiple courses of vancomycin. Wait there’s more…

13. The surgical wound is now healed, but she continues to note pain in her pelvis that she feels has only been resolved by IV vancomycin previously. • She describes being diagnosed with Fibromyalgia, low back pain, HA and generalized large joint pains. • She endorses h/o painful intercourse, painful menses • She notes she has been evaluated in the ED too many times to count dating back to childhood and that she has had multiple practitioners not know what to do which has led to ‘firing’ many of them. • She does endorse a history of tumultuous interpersonal relationships, some history of domestic violence and a childhood that was less than nurturing. • She denies depressive or significant anxiety symptoms. She does not see any possible relationship of her symptoms to recent psychosocial stressors to include her male ‘roommate’ moving out. She denies substance abuse history. • Lab studies unremarkable. That’s probably enough info…

14. Differential anyone? • Complications of her multiple surgeries, such as adhesions, abscess or other infectious etiologies or autoimmune condition • Substance abuse • Factitious disorder • Malingering • Where’s the significant secondary gain?? Somatization Disorder

15. Clinical Vignette: The medical service requests a consult, the pt is demanding unnecessary trx, pain out of proportion. • 28 yo SWF c/o pelvic pain, N and V requesting IV vancomycin for her “pelvic infection.” She vaguely describes some vaginal discharge. • She is afebrile with stable vital signs otherwise. • H/o unilateral oophorectomy d/t pain of ovarian cyst and endometriosis 4 months prior. Post-op course was “complicated” by soft tissue infection requiring multiple courses of vancomycin.

16. The surgical wound is now healed, but she continues to note pain in her pelvis that she feels has only been resolved by IV vancomycin previously. • She describes being diagnosed with Fibromyalgia, low back pain, HA and generalized large joint pains. • She endorses h/o painful intercourse, painful menses. • She notes she has been evaluated in the ED too many times to count dating back to childhood and that she has had multiple practitioners not know what to do which has led to ‘firing’ many of them. • She does endorse a history of tumultuous interpersonal relationships, some history of domestic violence and a childhood that was less than nurturing. • She denies depressive or significant anxiety symptoms. She does not see any possible relationship of her symptoms to recent psychosocial stressors to include her male ‘roommate’ moving out. She denies substance abuse history. • Lab studies unremarkable. Who knows the mnemonic?...

17. Somatization Disorder: • There is a history of many physical complaints, beginning before the age of 30. • Each of the following criteria must have been met: • Four pain symptoms (4 Pain) • Two gastrointestinal symptoms (2 Stomachs) • One sexual symptom (1 Sex) • One pseudoneurologic symptom (Convert) • Each symptom cannot be fully explained by a known medical condition, or, if there is a demonstrated medical condition, the impairment is in excess of what would be expected. Mnemonic: Recipe 4 Pain: Convert 2 stomachs to 1 sex

18. The Blind Blogger • 27 yowoman, no significant med hx • Presents to ER with c/o blindness • Neuro& fundoscopicexam neg, workup (CT, MRI, EEG) negative • Family history: Sister w/juvenile Macular Dystrophy • Onset of symptoms after discovering boyfriend’s infidelity on facebook

19. The Developing Daddy • 35yo male • Presents to PCP complaining of weight gain, indigestion, variable appetite, constipation, headache, and toothache. • His wife is in her late third trimester, but symptoms started in her third gestational month indigestion • He is somewhat embarrassed by his appearance

20. The Worried Weatherman • 45yo man • 6thprimary care in 6 weeks • Complains of mild headache, worries that he has brain tumor • Neuro exam: wnl • CT head: negative • Pt still worries that he has cancer

21. The anorexic Anarchist • 22 yoman with few year history of diffuse abdominal pain, persistent - limiting intake • Negative medical hx, some alcohol and illicits • Started after dropped out, has not returned to college • No longer participates in rallies due to pain • Multiple exams, labs, EGD, abdxray and CT unrevealing of source • Dietary changes, PPI, OTC analgesics of little benefit; opiate analgesics transiently relieving

22. The Demanding Diva • 75yo female • Presents to plastic surgeon complaining of wrinkles, demanding more botox • History of multiple prior cosmetic procedures and injections • Embarrassed by appearance

23. Undifferentiated Somatoform Disorder • One or more physical complaints cannot be fully explained by medical condition/substances, lasting 6 or more months, do not fulfill criteria for Somatization d/o – generally similar characteristics just fewer symptoms Somatoform D/O NOS • Pseudocyesis; non-psychotic hypochondriacal symptoms < 6 months; unexplained physical symptoms < 6months Differ from Conversion b/c symptoms physical and time

24. Conversion Disorder • Neurological (voluntary motor or sensory) symptoms or deficits that are associated with psychological factors that cause significant distress • Symptoms or deficits are not intentionally produced • Typically begin abruptly and dramatically • La belle indifference (not pathognomonic, no prognostic value) – not distressed • Psychodynamic views – primary gain, e.g. a conflict about aggression expressed by paralyzed arm • Most patients show rapid response to treatment • Pseudosz, amnesia, tremor more likely to have poor outcome – sig relationship to childhood (sexual) trauma Pseudoseizures, paralysis, amnesia, blindness, ataxia, deafness…

25. Pain Disorder • The primary criteria require that pain be the primary complaint and that it causes significant distress or functional impairment. • Psychological factors have important role. • Not intentionally produced. • Not better accounted for by Mood, Anxiety or Psychotic D/O, not meet criteria for Dyspareunia • Types: • Associated with Psychological Factors • Associated with both Psychological Factors and a General Medical Condition Pain is the most common reason a patient presents to a physician for evaluation.

26. Hypochondriasis • Core feature is fear of disease or a conviction that one has a disease despite normal physical exam results and investigations and physician reassurance. At least 6 months. • In clinical practice sorting out delusional from non-delusional hypochondriasis is sometimes difficult. Can the person consider the possibility that the feared disease is not present? • Primary hypochondriasis appears to be chronic – potentially better classified as a personality style or trait, worsens with stress. • Preoccupation not better accounted for by GAD, OCD, Panic D/O, MDE, Sep Anxiety or other Somatoform D/O ‘Hypochondria is the only illness that I don't have.’

27. Body DysmorphicDisorder • The preoccupation with an imagined defect in appearance (if a slight anomaly is present, the individual’s concern with it is judged to be markedly excessive*) that is accompanied by significant distress or impairment in social or occupational functioning. • Increasingly seen as an OCD spectrum disorder. • Delusional BDD may represent a difference in insight rather than a distinct syndrome. • MDD is highly comorbid, OCD, social phobia, substance use as well. • “Normal body disastisfaction” exists, duh Anyone watch the Hills?

28. Management.. Limit settingand caring rather than curing…

29. Recommended potential management approaches: • 1) Reattribution approach – linking symptoms to psychological stressors. Good for those with some insight, primary care settings. • 2) Psychotherapeutic - focus upon trusting relationship, persistent somatizers. • 3) Directive – interventions framed in medical model, hostile patients who deny psychological or social factors in their symptomatology. Evidence suggests the best choice for most patients is management by their PCP in consultation with a shrink.

30. Exercise, PT • Relaxation, Meditation, Hypnotherapy • Behavioral (Exposure forHypochondriasis) • Suggestion and reassurance (emphasizing lack of serious illness diagnoses and likelihood of improvement through activity) • CBT (may be preferred for Hypochondriasis, Somatization) • Dynamic, Group, Family Psychotherapies • Medications (target comorbidities, antidepressants, SSRI/TCA’s primarily) Avoid explanations that are heard as, “It’s all in your head,” duh

31. The Fatigued Farmer • 58 yo man whose farm is failing • No sequelae of chemical exposure on repeated exhaustive medical evaluations • Pursuing disability • Litigation against chemical fertilizer company

32. The Anemic Aide • 31 yo single female surgical nurse aide • Refractory and poorly characterized anemia • Recent break up with surgery resident • Found with extra butterfly needles on her person at work

33. Deception Syndromes…

34. Deception Syndromes • Factitious Disorder • NOS (Proxy types here) • Predominantly physical signs/sxs • Predominantly psychological signs/sxs • Combined • Malingering • Less a diagnosis than a socially unacceptable behavior with legal ramifications – assigned a V code “Just because I’m faking it doesn’t mean I ain’t sick.”

35. Factitious Disorder (common - physical) • Intentional production or feigning of physical signs/sxs, behaviors are surreptitious (stealthy) • Motivation for the behavior is to assume sick role (unconscious) • External incentives for the behavior or improving physical well being are absent • No aliases generally or travel from hospital system to system Common risk factors: F, single, 30’s, prior health care work, cluster B PD w/Borderline fx.

36. Factitious Disorder (Munchausen’s) • Same criteria with self-induction of disease, but more pervasive with use of aliases while ‘hospital hopping,’ & pseudologiafantastica (pathological lying – grandiose storytelling) • Munchausen’s by Internet? Seriously? Yup, DSM-V Common risk factors: M, single, 40’s, Cluster B PD w/ASPD fx

37. Among the most common presentations of self induced illness have been chest pain, endocrine disorders, coagulopathies, infections and neurological symptoms. • Diagnostic clues include Low C-peptide, dissociation of fever and pulse, laxative in stool, high urinary K (diuretics), serum assays for anticoag, etc., low serum thyroglobulin But what about feigned psychological symptoms?...

38. Factitious Disorder Primarily Psychological.. • Majority of factitious disorders describe physical symptoms alone. • Factitious psychological symptoms are generally in association with either authentic or fabricated physical symptoms • Ganser’s syndrome – approximate answers, closely related to factitious, feigning dementia

39. One of my patients as a resident was a former Duke and Syracuse Basketball player & CEO of a drug company, who suffered with “anxiety,” though he never accepted prescriptions for the medications he was “taking” and internet searches never revealed any evidence and he was only in his early 30’s.

40. Proposed motivations for factitious disorder: • Need to be center of attention • Longing to be cared for • Maladaptive reaction to loss or separation • Anger at physicians or displaced onto them • Pleasure derived from deceiving others (“duping delight”) So how do we manage this stuff?

41. Management and Treatment • Indirect confrontation or risk hostility, departure AMA, threats of law suits • Ex: ‘Some patients may do something to themselves as a way of seeking help…’ • Treat comorbid psychiatric issues (Depression, PD, Anxiety, Substance abuse) with meds and psychotherapy. • Supportive Psychotherapy may allow for relationship not contingent upon new physical symptoms Invasive/risky diagnostic and treatment procedures should be based on objective evidence only.

42. Factitious Disorder by Proxy – actually covered by Factitious NOS per DSM-IV • Also known as Munchausen’s by Proxy Parents (usually mom) who have induced disease in their children.

43. Differential for Munchausen by Proxy: • Pediatric Somatization Syndromes • Somatoform Disorder by proxy (parent’s anxiety projected onto child) • Infanticide/Murder • Psychosis in parent • Child abuse (garden variety) • Factitious behavior initiated by child • Malingering by child (school rejection) • Unrecognized physical disease Blended form of the condition in which child self-produces symptoms w/aid of parent

44. Angel of Death Syndrome • Hospital Epidemics of Factitious Disorder by Proxy – better described as serial murder Orville Lynn Majors, Clinton, Indiana, at least 130 murdersRichard Angelo, Long Island, New York, at least 10 murdersMichael Swango, New York, at least 4 murdersDr. Shipman one of the world's most prolific serial killers, claiming at least 215 victims in Britain.Genene Jones, Texas, at least 20 murdersEfrenSaldivar, California, at least 6 murdersBeverley Allitt, Britain, at least 4 murders

45. Malingering • By definition – motivated by specific, recognizable external incentives to produce, exaggerate or simulate physical or psychological illness Hoover’s sign..but what’s the motivation?

46. Malingering • Embellishment of previous or concurrent illness is most commonly encountered • Symptoms tend to disappear when the person obtains the desired goal or is confronted with irrefutable evidence – though not always • REMINDER: more of an accusation of external motives than a psychiatric diagnosis • HOWEVER: presence of secondary gains are NOT evidence of malingering per se. Specific neuropsych testing can occasionally be useful.

47. Rule out malingering in… • Patients on disability. • Patients involved in litigation related to a psychiatric condition. • Patients seeking a prescription for a controlled substance during the initial interview. Story too perfect, too vague, nothing works, heard about this medication Xanax from a friend…

48. CONTINUUM Conversion Malingering opposite poles of purely unconscious and purely conscious motivation Difficult at any given moment to know where the patient is on this continuum Pt’s with somatoform d/o’s are generally consistent in their symptom presentation regardless of audience/observation

49. Remember that we cannot cure unexplained illness, but we can care for those afflicted by them….which generally helps.

50. Levenson, James, and American Publishing. The American Psychiatric Publishing textbook of psychosomatic medicine. Arlington, VA: Amer Psychiatric Pub Inc, 2005. 271-309. Print. • The Psychiatric Interview, Practical Guides in Psychiatry. 'Ed'. Daniel J Carlat. Newburyport, MA: Lippincott Wiliiams& Wilkins, 2005. Print. References