Anxiety, Somatoform and Factitious Disorders, and Malingering

Anxiety, Somatoform and Factitious Disorders, and Malingering
د.وليد العميدي
I. ANXIETY DISORDERS
A. Fear and anxiety
1. Fear is a normal reaction to a known, external source of danger.
2. In anxiety, the individual is frightened but the source of the danger is not known, not recognized, or inadequate to account for the symptoms.
3. The physiologic manifestations of anxiety are similar to those of fear. They include
a. Shakiness and sweating
b. Palpitations (subjective experience of tachycardia)
c. Tingling in the extremities and numbness around the mouth
d. Dizziness and syncope (fainting)
e. Gastrointestinal and urinary disturbances (e.g., diarrhea and urinary frequency)
f. Mydriasis (pupil dilation)
B. Classification and occurrence of the anxiety disorders
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) classification of anxiety disorders includes
a. Panic disorder (with or without agoraphobia)
b. Phobias (specific and social)
c. Obsessive-compulsive disorder (OCD)
d. Generalized anxiety disorder (GAD)
e. Post-traumatic stress disorder (PTSD)
f. Acute stress disorder (ASD).

DSM-IV-TR Classification of the Anxiety Disorders and Adjustment Disorder
1- Panic Disorder (With or Without Agoraphobia)
- Episodic (about twice weekly) periods of intense anxiety (panic attacks)
- Cardiac and respiratory symptoms and the conviction that one is about to die or lose one s mind
- The anxiety disorders are the most commonly treated mental health problems.
- Sudden onset of symptoms, increasing in intensity over a period of approximately 10 minutes, and lasting about 30 minutes (attacks rarely follow a fixed pattern)
- Attacks can be induced by administration of sodium lactate or CO2
- Strong genetic component
- More common in young women in their 20s
- In panic disorder with agoraphobia, characteristics and symptoms of panic disorder (see above) are associated with fear of open places or situations in which the patient cannot escape or obtain help (agoraphobia)
- Panic disorder with agoraphobia is associated with separation anxiety disorder in childhood
2- Phobias (Specific and Social)
- In specific phobia, there is an irrational fear of certain things (e.g., elevators, snakes, or closed-in areas)
- In social phobia (aka social anxiety disorder), there is an exaggerated fear of embarrassment in social situations (e.g., public speaking, eating in public, using public restrooms)
- Because of the fear, the patient avoids the object or situation
- Avoidance leads to social and occupational problems
3- Obsessive-Compulsive Disorder (OCD)
- Recurring, intrusive feelings, thoughts, and images (obsessions) that cause anxiety
- Anxiety is relieved in part by performing repetitive actions (compulsions)
- A common obsession is avoidance of hand contamination and a compulsive need to wash the hands after touching things
- Obsessive doubts lead to compulsive checking (e.g., of gas jets on the stove) and counting of objects, obsessive need for symmetry leads to compulsive ordering and arranging and obsessive concern about discarding valuables leads to compulsive hoarding
- Patients usually have insight (i.e., they realize that these thoughts and behaviors are irrational and want to eliminate them)
- Usually starts in early adulthood, but may begin in childhood
- Genetic factors are involved
- Increased in first-degree relatives of Tourette disorder patients

4- Generalized Anxiety Disorder
- Persistent anxiety symptoms including hyperarousal and worrying lasting 6 months or more
- Gastrointestinal symptoms are common
- Symptoms are not related to a specific person or situation (i.e., free-floating anxiety)
- Commonly starts during the 20s

5- Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)
- Symptoms occurring after a catastrophic (life-threatening or potentially fatal event (e.g., war, house fire, serious accident, rape, robbery) affecting the patient or the patient s close friend or relative
- Symptoms can be divided into four types:
(1) reexperiencing (e.g., intrusive memories of the event [flashbacks] and nightmares)
(2) hyperarousal (e.g., anxiety, increased startle response, impaired sleep, hypervigilance)
(3) emotional numbing (e.g., difficulty connecting with others)
(4) avoidance (e.g., survivor s guilt, dissociation, and social withdrawal)
- In PTSD, symptoms last for more than 1 month (sometimes years) and may have a delayed onset
- In ASD, symptoms last only between 2 days and 4 weeks

6- Adjustment Disorder
- Emotional symptoms (e.g., anxiety, depression, conduct problems) causing social, school, or work impairment occurring within 3 months and lasting less than 6 months after a serious (but usually not life-threatening) life event (e.g., divorce, bankruptcy, changing residence)
- Symptoms can persist for more than 6 months in the presence of a chronic stressor.




C. The organic basis of anxiety
1. Neurotransmitters involved in the development of anxiety include ?-aminobutyric acid (GABA) (decreased activity), serotonin (decreased activity), and norepinephrine (increased activity) .
2. The locus ceruleus (site of noradrenergic neurons), raphe nucleus (site of serotonergic neurons), caudate nucleus (particularly in OCD), temporal cortex, and frontal cortex are brain areas likely to be involved in anxiety disorders.
3. Organic causes of symptoms of anxiety include excessive caffeine intake, substance abuse, hyperthyroidism, vitamin B12 deficiency, hypoglycemia or hyperglycemia, cardiac arrhythmia, anemia, pulmonary disease, and pheochromocytoma (adrenal medullary tumor).
4. If the etiology is primarily organic, the diagnoses substance-induced anxiety disorder or anxiety disorder caused by a general medical condition may be appropriate.

D. Treatment of the anxiety disorders
1. Antianxiety agents (see Chapter 16), including benzodiazepines, buspirone, and ?-blockers, are used to treat the symptoms of anxiety.
a. Benzodiazepines are fast-acting antianxiety agents.
(1) Because they carry a high risk of dependence and addiction, they are usually used for only a limited amount of time to treat acute anxiety symptoms.
(2) Because they work quickly, benzodiazepines, particularly alprazolam (Xanax), are used for emergency department treatment of panic attacks.
b. Buspirone (BuSpar) is a non-benzodiazepine antianxiety agent.
(1) Because of its low abuse potential, buspirone is useful as long-term maintenance therapy for patients with GAD.
(2) Because it takes up to 2 weeks to work, buspirone has little immediate effect on anxiety symptoms.
c. ?-blockers, such as propranolol (Inderal), are used to control autonomic symptoms (e.g., tachycardia) in anxiety disorders, particularly for anxiety about performing in public or taking an examination.
2. Antidepressants.
a. Antidepressants, including monoamine oxidase inhibitors (MAOIs), tricyclics, and especially selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft), are the most effective long-term (maintenance) therapy for panic disorder and for OCD.
b. Recently, SSRIs (e.g., escitalopram [Lexapro]) and the selective serotonin and norepinephrine reuptake inhibitors (SSNRIs) venlafaxine (Effexor) and duloxetine (Cymbalta) were approved to treat GAD.
c. Paroxetine, sertraline, and venlafaxine now also are indicated in the treatment of social phobia.
3. Psychological treatment .
a. Systematic desensitization and cognitive therapy (see Chapter 17) are the most effective treatments for phobias and are useful adjuncts to pharmacotherapy in other anxiety disorders.
b. Behavioral therapies, such as flooding and implosion, also are useful
c. Support groups (e.g., victim survivor groups) are particularly useful for ASD and PTSD.


II. SOMATOFORM DISORDERS
A. Characteristics and classification
1. Somatoform disorders are characterized by physical symptoms without sufficient organic cause.
2. The patient thinks that the symptoms have an organic cause but the symptoms are believed to be unconscious expressions of unacceptable feelings .
3. Most somatoform disorders are more common in women, although hypochondriasis occurs equally in men and women.
DSM-IV-TR Classification of the Somatoform Disorders
Classification Characteristics
Somatization disorder History over years of at least two gastrointestinal symptoms (e.g., nausea), four pain symptoms, one sexual symptom (e.g., menstrual problems), and one
pseudoneurological symptom (e.g., paralysis)
Onset before 30 years of age
Hypochondriasis Exaggerated concern with health and illness lasting at least 6 months
Concern persists despite medical evaluation and reassurance
More common in middle and old age
Goes to many different doctors seeking help ("doctor shopping")
Conversion disorder Sudden, dramatic loss of sensory or motor function (e.g., blindness, paralysis),
often associated with a stressful life event
More common in unsophisticated adolescents and young adults
Patients appear relatively unworried ("la belle indifférence")
Body dysmorphic disorde Excessive focus on a minor or imagined physical defect
Symptoms are not accounted for by anorexia nervosa
Onset usually in the late teens
Pain disorder Intense acute or chronic pain not explained completely by physical disease and closely associated with psychological stress
Onset usually in the 30s and 40s
B. Differential diagnosis
1. The most important differential diagnosis of the somatoform disorders is unidentified organic disease.
2. Factitious disorder (see below), malingering (faking or feigning illness), and masked depression also must be excluded.
C. Treatment
1. Effective strategies for treating patients with somatoform disorders include
a. Forming a good physician-patient relationship (e.g., scheduling regular appointments, providing reassurance)
b. Providing a multidisciplinary approach including other medical professionals (e.g., pain management, mental health services)
c. Identifying and decreasing the social difficulties in the patient s life that may intensify the symptoms
2. Antianxiety and antidepressant agents, hypnosis, and behavioral relaxation therapy also may be useful

III. FACTITIOUS DISORDER (FORMERLY MUNCHAUSEN SYNDROME), FACTITIOUS
DISORDER BY PROXY, AND MALINGERING
A. Characteristics
1. While individuals with somatoform disorders truly believe that they are ill, patients with factitious disorders and malingering feign mental or physical illness, or actually induce physical illness in themselves or others for psychological gain (factitious disorder) or tangible gain (malingering) .
Factitious Disorder, Factitious Disorder by Proxy, and Malingering
Disorder Characteristics
Factitious disorder (formerly Munchausen Syndrome) Conscious simulation of physical or psychiatric illness to gain attention from
medical personnel
Undergoes unnecessary medical and surgical procedures
Has a "grid abdomen" (multiple crossed scars from repeated surgeries)
Factitious disorder by proxy Conscious simulation of illness in another person, typically in a child by a parent, to obtain attention from medical personnel
Is a form of child abuse because the child undergoes unnecessary medical and surgical procedures
Must be reported to child welfare authorities (state social service agency)
Malingering Conscious simulation or exaggeration of physical or psychiatric illness for financial (e.g., insurance settlement) or other obvious gain (e.g., avoiding
incarceration)
Avoids treatment by medical personnel
Health complaints cease as soon as the desired gain is obtained



2. Patients with factitious disorder often have worked in the medical field (e.g., nurses, technicians) and know how to persuasively
simulate an illness.
3. Malingering is not a psychiatric disorder.
B. Feigned symptoms
most commonly include abdominal pain, fever (by heating the thermometer), blood in the urine (by adding blood from a needle stick), induction of tachycardia (by drug administration), skin lesions (by injuring easily reached areas), and seizures.
C.When confronted by the physician with the fact that nothing can be found, patients with factitious disorder or patients who are malingering typically become angry and abruptly leave.