Review of Diagnostic Categories and Management of “Counter-Transference”

01-10-2011

Several diagnoses within this categoryCommon theme is somatization of

psychological distress, with either no evidence of psychological abnormality, or symptoms disproportionate to severity of identified abnormality

Estimated 25% of general ambulatory population with some degree of somatization, estimated 10% of these with no evidence whatsoever of physiological abnormality

Symptoms may be fluid over time- rule rather than exception

Barsky AJ et al. Med Care 2001; 39;705-15

• Conversion Disorder• Somatization Disorder• Undifferentiated Somatoform Disorder• Hypochondriasis• Body Dysmorphic Disorder• Pain Disorder• Somatoform Disorder NOS

Will limit discussion to Conversion, Somatization, Undifferentiated Somatoform

A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition

B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors

C. Symptom or deficit is not intentionally produced or feigned

D. Symptom or deficit cannot, after appropriate investigation, be FULLY explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience

• Causes clinically significant distress or impairment in social, occupational, or or other important areas of functioning, or warrants medical evaluation

• Symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively in the context of somatization disorder, and is not better accounted for by another mental disorder

Little is known about epidemiology- wide variability in reported prevalence, but some estimates as high as 33% lifetime (to some degree) in adult women

Higher incidence in adult women than in adult men

More common in those with below average intelligence, less formal education or social sophistication, and in those with conditions that inhibit verbal expression of symptoms

Ford CV. Treatment of Pscyh Disorders, 3rd ed. 2001, 1755-76.

Differential diagnosis includes factitious disorder, malingering, identifiable “physical” disease

Comorbidities are varied, and may include depression, other mood disorders, anxiety-spectrum conditions, and personality disorders (most common)

Treatment is limited psychopharmacology for comorbid mood or anxiety disorders, psychotherapy (good luck), and symptomatic treatment

Symptoms usually resolve spontaneously, unless strong perpetuating factors exist.

Treatment Recommendations:• Talk to the patient- take a THOROUGH history and

obtain ancillary information to gain insight to recent psychosocial situation

• Obtain specialist consultative opinion in face of diagnostic uncertainty (usually neurology, but may include medicine specialty or surgical consults)

• Work-up ANY medical abnormalities that are present- make no assumptions and do not “explain away” abnormal findings in order to confirm your preconceived suspicions about the patient- this is how people succeed in winning lawsuits against you!

• Treat comorbid disorders- if present- aggresively

Somatization DisorderA.History of many physical complaints beginning

before age 30 that occur over a period of several years and result in treatment being sought or significant impairment

B.Each of the following criteria must be met at some time during course of illness:

- Four pain symptoms- Two GI symptoms- One sexual symptom other than pain- One pseudoneurological symptom

After appropriate investigation, each of the symptoms cannot be fully explained by a know general medical condition, or dierct effect of substance

When there is a related general medical condition, the complaints or resulting impairment are in excess of what would be explained from the history, physical examination, or laboratory findings

A. One or more physical complaintsB. Cause clinically significant distress or

impairmentC. Duration of at least 6 monthsD. Symptom or deficit is not intentionally feigned

or producedE. Not better accounted for by another mental

disorder and:- Each of symptoms in A cannot be fully explained

by a known GMC or direct effects of substance- When there is a related GMC, the distress or

impairment is disproportionate to the findings

Hard to estimate due to “doctor shopping” that reduces detection

Specific criteria for somatization results in lower prevalence (ECA studies suggest 0.1-0.4% of population)

Undifferentiated Somatoform likely much more prevalent, and quite common in primary care settings (ECA estimates 4-11% of general population)

True Somatization Disorder patients tend to be female, unmarried, minority, poorly educated, and from rural backgrounds

Patients with this disorder often come from chaotic, unstable backgrounds with regard to family of origin- alcohol or other drug abuse is often present in one or more primary family members who had a formative role in the patient’s life

Most common comorbidities include MDD and personality disorders

Mai F. Canadian Journal of Psychiatry 2004; 49:652-62.

Treatment Recommendations:• History, as with conversion disorder- keys to focus

on are PMH, PSH- DURATION is key- patients with these disorders have long duration of symptoms which do not remit, and history will likely document this pattern

• As with conversion, aggressively work-up all objective abnormalities

• DO NOT order potentially risky diagnostic procedures on subjective complaints alone- DO NOT repeat diagnostic procedures unless OBJECTIVE evidence of a change in clinical status exists

• Treat any potentially treatable psychiatric comorbidities aggressively

Ebert MH et al. eds. Current Diagnosis and Treatment in Psychiatry. Lange 2008:396

ibid. 398

A. Intentional production or feigning of physical or psychological signs or symptoms

B. The motivation of the behavior is to assume the sick role

C. External incentive for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent

Incidence/Prevalence are unknown, and estimates are fraught with difficulty, given rather inherent diagnostic uncertainty, fear re: reporting, etc.

Generally thought to be far lower than somatoform disorders, where factitious disorder is concerned

Frank Malingering probably more common that factitious disorder, but less likely to present in primary care clinics- especially if PCP is vigilant regarding prescribing of schedule II substances

Among factitious, most common profile is unmarried female, 20s to early middle-age, often employed in health service fields

Among “classic” Munchausen, profile is early middle-age male, estranged from family

Krahn LE et al. Am J Psychiatry 2003; 160:1163-8.

Treatment Recommendations:• Avoid confronting patient with direct evidence of

factitious/malingering behavior- equivocate when confronting, avoid expressing open disdain

• Attempt to empathize- often these patients have HORRIBLE social lives, and all have exhausted their coping skills

• Involve social work early, and report any reportable neglect/abuse, etc. Present a “unified front” so splitting is minimized

• Probably a better role for supportive or cognitive psychotherapy here

• Aggressively treat all treatable psychiatric comorbidities• Remember- you won the lottery- be obsequious if you have

to, then go home and vent!

There will be! You will rarely be able to determine which of these diagnoses

are in play upon initial evaluation Diagnoses should be reported as a differential There are no pathognomonic findings, and no objective

evidence in many cases. Ancillary information is most useful, as patient almost always

(consciously or not) has a motivation to obfuscate their presenting situation, to some extent

Motivations include various conscious and unconscious goals, and it is EXTREMELY rare for patients to come in with the goal of making your life harder- they have plenty of their own problems to worry about

Focus more on uncovering perpetuating and precipitating factors, rather than trying to arrive at the “right diagnosis.”

A suspicion based upon broad data obtained by objective facts in past history and ancillary report is usually as good as it gets

Don’t take the bait and react emotionally to your own presuppositions regarding the patient’s presentation and suspected motivations- your suspicions will usually be wrong, anyway

Don’t assume the patient is enjoying what is going on any more than you are- they usually aren’t

Do verbally acknowledge patient’s emotional reactions to their problems- helping the patient to feel validated will help you to help them

Do prepare to spend a lot of time with these patients on rounds- if you don’t, I promise you it will backfire!

Remember, even if the patient is below average intelligence, they know what you are feeling if you show them; MOST are not suffering from autistic disorder

Don’t assume there is nothing wrong “physically.” MOST of these patients have both physical AND mental disorders

Do get used to disappointment if you do poorly with subjectivity/uncertainty. Although there will rarely be “correct” answers in dealing with these patients, take comfort in knowing that the absence of a “right” answer means you will rarely be wrong.

Remember, MOST people will rarely attempt to sue you unless the following things happen: 1) you act like an asshole 2) you perform an unnecessary diagnostic/therapeutic maneuver and harm the patient

Remember- #1 is much more likely to get you sued than #2