Psychosomatic Disorders

Here are some questions you could ask.

What is your main concern today? Everyone has a different perspective of their problems. For Jackie, it’s seizures; she doesn’t recognize any anxiety or depression.

How do you define the cause of your seizures? Review the timeline of the seizures and compare to significant changes in her relationships and jobs.

Have you ever not had anxiety before a seizure? How often does she experience a seizure, and what does she do when anxiety worsens?

Do you feel sad, mad, or stuck about your divorce and stressful job? Do these stressors affect your self-esteem, or do you feel guilty about your divorce or job?

What is one situation or feeling that makes you anxious? Perhaps she will be able to identify her divorce and job on her own.

What feelings did you have just before your last seizure? Jackie has a difficult time defining/describing her feelings. Discussing her physical and emotional symptoms before a seizure allows Jackie to identify depression/anxiety.

What did you think about before your last seizure? This allows Jackie to identify thoughts that are difficult to describe, linking her external seizure to the internal depression/anxiety.

What can you do to change your feelings about the divorce and job stressors? How can you help Jackie change what she thinks about anticipating seizures that will help her feel better? This helps Jackie to change her perspective and improve the depression/anxiety.

These questions can lead to identification of depression and anxiety. This realization allows the following questions:

Is there a primary gain that allows Jackie to keep internal conflicts outside her awareness? Is there a symbolic value of her symptoms that represents an unconscious psychological conflict?

Is there a secondary gain? Does Jackie's illness excuse her from social and occupational obligations?

As treatment progresses and after Jackie identifies depression/anxiety, you can ask Jackie to rate depression/anxiety as mild/moderate/severe. This allows Jackie and you to determine effectiveness of the treatment.

Functional neurological symptom disorder (conversion disorder) is the correct diagnosis. Depressive disorder, generalized anxiety disorder, histrionic personality disorder, passive-dependent personality disorder, schizophrenia, and somatic symptom disorder would be appropriate differential diagnoses.

The following are characteristics of functional neurological symptom disorder, along with generalized anxiety disorder, depressive disorders, and histrionic personality disorder for comparison.

Functional neurological symptom disorder: This condition is more common in women and those assigned female at birth (AFAB) and is rare after the age of 35 (Jackie is only 29). It is associated with MDD, GAD, anxiety diagnosis, schizophrenia, and histrionic/passive dependent personality disorders. Functional neurological symptom disorder can occur with no predisposing medical, neurological, or psychiatric disorder.

Functional neurological symptom disorder involves symptoms rather than a particular disease. A person develops physical symptoms that are not under voluntary control and are not explained by a neurological disease or another medical condition. Key feature: incompatibility between an individual’s symptoms and recognized neurological or medical conditions.

1. One or more somatic symptoms that are distFrom the DSM-5-TR section on functional neurological symptom disorder (conversion disorder), the diagnostic criteria are:
   1. One or more symptoms of altered voluntary motor or sensory function.
   2. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
   3. The symptom or deficit is not better explained by another medical or mental disorder.
   4. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Persistent course is characterized by severe symptoms (such as Jackie’s pseudo seizures) and marked impairment (avoiding social outings and missing work obligations), lasting more than 6 months.

Jackie’s condition is severe because two or more symptoms have been fulfilled, plus one very severe somatic symptom (multiple somatic complaints – migraines/seizure).

Generalized anxiety disorder: Excessive anxiety and worry occurring more days than not about a variety of topics, events, or activities. Worry occurs more often than not for at least 6 months and is clearly excessive. Worry is experienced as very challenging to control.

Depressive disorder: Jackie has some symptoms of worthlessness, helplessness, and/or hopelessness related to her job. She does not, however, report trouble concentrating, remembering details, making decisions, fatigue, guilt, disruptive or excessive sleep, irritability, anhedonia, persistent sadness, suicidal thoughts, or other hallmarks of depression. It is unlikely this would be a primary diagnosis, but she may have some depression related to the divorce that she cannot yet verbalize.

Histrionic personality disorder: Interests and conversation will be self-focused (self-centered). Patients seek reassurance or approval and have opinions that are easily influenced by other people. They exhibit excessive dramatics and exaggerated displays of emotion. Passive dependent type: Patients show a pervasive fear that leads to clinging behavior that is seen by early adulthood. They have difficulty making decisions, even with an excessive amount of advice and reassurance from others. Patients have an anxious personality characterized by an inability to be alone, and to rely on the comfort, reassurance, advice, and support of others. Given Jackie’s statements about her ex-husband, histrionic personality disorder is an unlikely diagnosis; she was not easily swayed by their differences.

Symptoms of acute deficits are usually of short duration and remit spontaneously. If symptoms have been present for 6 months or longer, the prognosis for symptom resolution is less than 50% and diminishes further the longer that conversion is present. Recurrence occurs in 20% to 25% of patients within 1 year of the first episode. One episode is a predictor for future episodes.

Good prognosis is predicted by an acute onset, the presence of clearly identifiable stressors at the time of onset, a short interval between onset and starting treatment, and above-average intelligence. Also, paralysis, aphonia, and blindness are associated with good prognosis. Poor prognosis is associated with tremor and seizures.

Jackie will benefit the most from insight-oriented psychotherapy to explore intrapsychic conflicts and the symbolism of functional neurological symptom disorder. CBT can help her recognize false beliefs, understand anxiety and physical symptoms, and manage stress. Motivational interviewing will prepare her for change and give her coping skills for internal conflict that presents as external seizures.

It would be appropriate to prescribe SSRIs or SNRIs because of Jackie’s work-related anxiety and depression related to her divorce, and to treat criteria symptoms of MDD and GAD. In addition, as needed, Jackie can use antihistamines and beta blockers for work anxiety while SSRI/SNRI builds to therapeutic doses. There is a benefit to adding Buspar onto an SSRI/SNRI to treat anxiety.

There is an overlap of MDD and anxiety symptoms, therefore SSRIs are a first-line approach to treat anxiety (poor concentration, fatigue, sleep disturbance).

If you decide that there is an MDD, use an SSRI or an SNRI.

For anxiety, a2 ligands, SSRIs, and SNRIs are the first line treatment; TCAs, mirtazapine, and trazodone are a second-line treatment.

To build a therapeutic alliance, offer Jackie a way to see her situation in a new non-blaming manner. This can be done by recognizing Jackie’s physical symptoms as real and connecting them to her anger at physicians and family who do not believe in her suffering. When Jackie trusts you, it allows you and Jackie the ability to agree that she indeed experiences real symptoms that provoke both seizures and anxiety.

Provide a nonjudgmental and safe environment by providing feedback that is informative and not judgmental. Feedback must be constructive and promote self-esteem such as acknowledgement of Jackie’s growth and focus on her strengths as therapy continues. This promotes trust and allows Jackie to correlate her physical symptoms to anxiety. Asking questions that allow clients to gain insight and develop new coping skills for anxiety will strengthen a therapeutic alliance. Lastly, assure Jackie that you will continue to work with her to improve functionality and monitor symptoms for any change in quality or quantity that will warrant further investigation.

Rely at first on open-ended questions. After Hayden has been given a chance to report his symptoms in his own words, ask specific, detailed questions that help to characterize symptoms as normal or abnormal, such as, “Will you tell me what led to your right-side pain?” Avoid leading questions in suspected malingering and later ask detailed questions that characterize symptoms as typical or atypical mental illness.

Ask him if he recognizes any secondary gain of the attention and sick role. You should be caring, non-judgmental and search for objective evidence of psychiatric disorders.

Observe Hayden closely. Does he suddenly appear more depressed when he thinks he is being observed versus unobserved?

The Test of Memory Malingering (TOMM) provides an objective, criterion-based test that can determine between bona-fide memory impairment and feigned symptoms of impaired memory. Often, malingering patients will present with memory problems inconsistent with screening tools developed for memory impairment. The TOMM is a 50-item visual test designed to help distinguish malingering from genuine memory impairments. Interpretation of the TOMM is made on the basis of the TOMM score that a patient achieves; if the score is less than 45/50, it’s suggestive of malingering.

SIRS-2 can be used to assess deliberate distortions in the sel- report of symptoms. Each scale produces information on how a patient might distort or make up their symptoms. There are 172 items, 32 of which are repeated inquiries to detect inconsistency of responses. Content covers a wide range of psychopathology and symptoms that are unlikely to be true. SIRS-2 detects response styles commonly associated with feigning and inconsistent responses that have implications of other treatment considerations.

Factitious disorder or malingering are the correct diagnoses. Factitious disorder requires an absence of obvious rewards and thus is more likely.

Hayden meets criteria for factitious disorder by the induction of injury (stabbing himself superficially) and association with identified deception (receiving medical attention). He presents himself as injured and presents deceptive behavior without obvious external rewards. His behavior is not better explained by delusion or psychosis, and he has two or more events of falsification of illness and one case of induction of injury.

Regarding malingering, Hayden’s complaints are grossly in excess of clinical findings, and he overacts and calls attention to his symptoms. His exaggerated pain symptoms do not fit any specific diagnostic criteria.

Malingering is differentiated from factitious disorder by the intentional reporting of symptoms for personal gain (for example, filing litigation for monetary gain, disability reimbursement and insurance, and so on). Malingers have an obvious, recognizable, environmental goal in producing signs and symptoms. They seek hospitalization to secure financial compensation, evade the police, avoid work, or obtain bed and board for the night; there is an apparent end for their behavior.

Factitious Disorder

• No known reason for adopting the sick role
• Can be attributed to psychological reasons
• More likely to undergo surgeries and extensive medical treatments
• Motivated by psychological needs (attention, security, and so on)

Malingering

• Child or adult fakes an illness for personal or secondary gain
• Deliberate
• Will not agree to unnecessary surgery or procedures
• More common in military populations and legal settings

Ask Hayden how to define the causes of pain and his abdominal wound. Listening to his concerns and providing support, as well as avoiding needless testing, is key.

Ask him about what he sees as the benefit of his testing requests despite them having ruled out diseases. You should obtain collateral information from his chart and family and friends if possible.

Malingerers can stop producing signs and symptoms when they no longer consider it a benefit, or the risk becomes too great. The course of factitious disorder is often intermittent; with recurrent episodes, it may be lifelong.

Family therapy will help everyone hurt by Hayden’s need to take on the sick role. CBT will help him understand and reduce compulsive behavior and acts of self-injury.

If other mental health issues are identified, you can treat those with psychotropics. Pharmacotherapy is of limited use in factitious disorder and malingering, and medication should be administered carefully because of the potential for abuse. SSRIs might be helpful in decreasing impulsive behavior when that is a major component in acting out factitious behavior. Given Hayden’s recent trip to the ER, this might be a concern.

To build a therapeutic alliance, offer Hayden a way to see his situation in a new, non-blaming manner. This can be done by recognizing Hayden’s physical symptoms as real and connecting them to his anger at physicians and family who do not believe in his suffering. When Hayden trusts you, it allows Hayden and you the ability to agree that he indeed experiences real symptoms that provoke pain and anxiety.

Do not accuse Hayden of lying.

Be wary of countertransference. When a provider countertransfers their feelings of frustration onto a patient, it results in division between the patient and provider. Seek clarification from Hayden rather than confrontation. Consider possible security measures because malingers can respond by escalating their behavior in an attempt to justify their physical illness. In extreme cases, malingerers might have physical aggression or self-injury in front of you.

Provide a safe environment by providing feedback that is informative and not judgmental. Feedback must be constructive and promote understanding, such as acknowledging Hayden’s situation and focusing on his strengths as therapy continues. Doing so promotes trust and allows Hayden to correlate his self-harm to factitious disorder or secondary gain. Ask questions that allow him to gain insight, which will strengthen the therapeutic alliance. Assure Hayden that you will continue to work with him to improve his personal and professional functionality and monitor his actions for any change in quality or quantity that will warrant further investigation.

Lastly, contact his PCP for medical conditions and keep in close contact with his PCP (after an ROI is obtained). Avoid unnecessary tests, medications, and hospitalizations in the absence of objective evidence of a psychiatric disorder and treat symptomatic relief.

Note: In cases of factitious disorder by proxy that involve children or elders, protection of the victim takes priority over your relationship with your client. Keep in mind legal reporting requirements.