Somatoform and Factitious Disorders

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Katharine A. Phillips: Somatoform and Factitious Disorders, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition.

Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc. DOI:

10.1176/appi.books.9781585622986.265215. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VII. Somatoform and Factitious Disorders >

Somatoform and Factitious Disorders

INTRODUCTION

Patients with somatoform and factitious disorders can be unusually challenging and difficult to

treat. These patients suffer greatly and are often highly distressed. Their day-to-day functioning

may be markedly impaired. Nonetheless, they may be reluctant to accept psychiatric care. These

patients may instead ardently pursue treatment from primary care physicians, surgeons,

dermatologists, neurologists, surgeons, or other specialists, seeking a medical solution to a

psychiatric problem—usually without alleviation of their symptoms. When medical or surgical

colleagues refer these patients to us, the patients may feel rejected. They may even refuse to see

us and instead go in search of a “better” dermatologist, neurologist, or surgeon.

Patients with somatization disorder or hypochondriasis typically go from doctor to doctor

requesting a plethora of medical tests, unable to accept reassurance that their symptoms do not

reflect physical illness. Patients with body dysmorphic disorder consider their perceived physical

deformity to be “real.” Convinced that their nose is misshapen, their head is too big, or something

else is wrong with how they look, they may pursue surgery or dermatological treatment, even when

past treatment has been disappointing. It also is not surprising that patients with conversion

disorder—who may experience blindness, deafness, or paralysis of a limb—may resist a

psychological explanation for deficits or symptoms they perceive as very real. Patients with

factitious disorder differ from those with somatoform disorders in that they consciously feign their

symptoms; thus, they typically avoid seeing us for another reason—so that their deception is not

detected.

We must approach these patients with special care and with a focus on establishing a good

therapeutic alliance at the very first visit. As is discussed in the chapters that follow, we must

attend to this alliance and maintain it throughout the treatment. Although this is essential with all

patients, regardless of their diagnosis, it is of paramount importance with patients with somatoform

and factitious disorders. Otherwise, we will have no patient to treat. When patients present with a

somatoform disorder, we must avoid dismissing their symptoms or implying that the symptoms are

imagined or “all in their head.” This is a delicate and complex process that involves conveying a

sincere interest in these patients and empathy for their suffering. We must provide information

about their symptoms and diagnosis without implying that they are “crazy”; at the same time, we

must not confirm their fears that they are truly medically ill or deformed. Many patients are

relieved to hear that their disorder is a recognized illness with a name and that with appropriate

treatment they can improve. We must convincingly convey that our treatment can help. For patients

with factitious disorder, direct confrontation of their deception appears seldom successful, because

they are likely to simply go to another physician. Instead, it may be helpful to explain that having a

complicated and puzzling medical condition is psychologically stressful and that this stress may be

adversely affecting their health.

The best approach to establishing an alliance has not been investigated in methodologically

rigorous studies such as randomized, controlled trials. Rather, the approach outlined in the

previous paragraph, and discussed at greater length in the chapters that follow, is based on clinical

wisdom and approaches used across psychotherapies to connect with and engage reluctant patients

in treatment. Once we develop an alliance, which may take multiple visits, we can begin to

implement effective evidence-based treatment. More methodologically rigorous treatment research

on the somatoform disorders is being done, with encouraging results. However, research onPrint: Somatoform and Factitious Disorders http://www.psychiatryonline.com/popup.aspx?aID=265219&print=yes…

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somatoform and factitious disorders is still limited—in fact, more limited than for many other

serious mental illnesses. Few controlled treatment studies have been done for a number of these

disorders, and much more treatment research is greatly needed to guide clinical practice. In this

section, the chapter authors note which recommendations are evidence-based, and when such

evidence is not available, their recommendations are based on clinical experience.

In Chapter 36, “Somatization Disorder and Undifferentiated Somatoform Disorder,” Mehmet Dokucu

and C. Robert Cloninger provide an excellent overview of how to successfully approach patients

with this often difficult-to-treat disorder. They recommend that a general practitioner be the central

coordinator of the patient’s health care. To date, only one randomized, controlled trial has

investigated the efficacy of psychotherapy for DSM-defined somatization disorder; this study found

that a time-limited, short-term group therapy approach with an emphasis on psychoeducation was

effective. Studies of patients who do not meet full criteria for somatization disorder suggest that a

number of therapeutic approaches are potentially beneficial, including behavioral therapy,

cognitive-behavioral therapy (CBT), relaxation, and hypnosis. Comorbid disorders may improve

with pharmacotherapy. Based on their clinical experience, the authors also discuss the importance

of enhancing patients’ well-being and self-awareness.

Chapter 37, “Conversion Disorder,” by José Maldonado, discusses the use of CBT and hypnotically

facilitated psychotherapy. Dr. Maldonado notes that selected patients may benefit from a

pharmacologically facilitated interview with amobarbital or lorazepam; however, because of the

potential legal ramifications of using memory enhancement methods, adequate training and

supervision are needed.

In Chapter 38, “Pain Disorders,” Steven King notes that a variety of psychotherapies appear

beneficial for pain, including many forms of individual, group, and family therapies. The most

commonly used approaches are operant conditioning and CBT, including biofeedback, relaxation

training, and hypnosis. Dr. King also provides a very useful review of pharmacological treatment

options (opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, antidepressants, and

anticonvulsants), and he addresses the risks of abuse and dependence that some medications

entail.

My own chapter (Chapter 39) on body dysmorphic disorder focuses on the use of serotonin

reuptake inhibitors (at relatively high dosages) and CBT. The chapter also emphasizes that

although body dysmorphic disorder appears to be relatively common, it is an often secret disorder

that is usually missed in clinical practice. The first essential steps in providing effective treatment

are to screen patients for the disorder, recognize clues to its presence, and accurately diagnose it.

In Chapter 40, “Hypochondriasis,” Brian Fallon and Arthur Barsky discuss a variety of therapeutic

strategies that may lead to positive results. The best evidence to date supports the efficacy of

cognitive therapy, exposure and response prevention, and pharmacotherapy. Psychodynamic

therapy may also be effective, although data are more limited.

Evidence-based treatment recommendations are especially limited for factitious disorder. In

Chapter 41, “Factitious Disorder and Malingering,” James Hamilton and Marc Feldman review the

available treatment literature and also suggest new working assumptions about factitious disorder

that promote the importance of early identification and early intervention when it is suspected.

The chapters in this section also address the importance of carefully coordinating psychiatric care

with the care provided by a nonpsychiatric physician. A coexisting general medical disorder can

readily complicate the treatment of somatoform or factitious disorders—and vice

versa—necessitating well-coordinated care. For example, patients with somatization disorder

appear to benefit most from well-coordinated care provided by both a psychiatrist and a primary

care physician. Similarly, when treating patients with conversion disorder, a purely medical

approach or a purely psychiatric approach often fails, and a joint medical/psychiatric approach

appears best. This approach ensures that any coexisting medical illness is adequately diagnosed

and treated. It also conveys the critical importance of caring for both body and mind.Print: Somatoform and Factitious Disorders http://www.psychiatryonline.com/popup.aspx?aID=265219&print=yes…

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Although research on the treatment of somatoform and factitious disorders is still limited, the

chapters that follow demonstrate that many patients can improve with currently available

treatments. We can approach the treatment of these patients with optimism, and, as more

treatment research is done, we will be able to offer even greater hope for recovery and well-being.

Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.