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15. True or false: The expression of an impulse disorder is more likely to occur under the influence of substances of abuse. True. Further, these disorders have considerable comorbidity with substance use disorders, as well as with mood disorders and personality disorders.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American PsychiatricAssociation, 1994. 2. DeCaria CM, Hollander E, Grossman R, et al: Diagnosis, neurobiology, and treatment of pathologic gambling. J Clin Psychiatry 57(suppl S):SSO-S84, 1996. 3. Drake ME, Hietter SA, Pakalnis A: EEG and evoked potentials in episodic-dyscontrol syndrome. Neuropsychobiology 26: 125, 1992. 4. Gerner RH: Pharmacological treatment of violent behaviors. In Rosner R (ed): Principles and Practice of Forensic Psychiatry. New York, Chapman and Hall, 1994, pp 444450. 5. Kavoussi R, Armstead P, Coccaro E: The neurobiology of impulsive aggression. Psychiatr Clin North Am 20(2):395-403, 1997. 6. Marohn RC, Custer R, Linden RD, et al: Impulse control disorders not elsewhere classified. In American Psychiatric Association: Treatments of Psychiatric Disorders: A Task Force Report of the American PsychiatricAssociation. Washington, DC, American Psychiatric Association, 1989, pp 2457-2496. 7. McElroy SL, Hudson J1, Pope HG, et al: The DSM-111-R impulse control disorders not elsewhere classified: Clinical characteristicsand relationship to other psychiatric disorders.Am J Psychiatry 149:318, 1992. 8. McElroy SL, Soutullo CA, Beckman DA, et al: DSM-IV intermittent explosive disorder: A report of 27 cases. J Clin Psychiatry 59:203-210, 1998. 9. Murray JB: Review of research on pathological gambling. Psycho1 Rep 72:791, 1993. 10. Schalling D: Neurochemical correlates of personality, impulsivity, and disinhibitory suicidality. In Hodgins S (ed): Mental Disorder and Crime. Newbury Park, CA, Sage, 1993, pp 208-226. 1 1 . Stein DJ, Hollander E, Liebowitz MR: Neurobiology of impulsivity and impulse control disorders. J Neuropsychiatry and Clin Nenrosci 5:9, 1993. 12. Virkkunen M, Linnoila M: Serotonin in personality disorder with habitual violence and impulsivity. In Hodgins S fed): Mental Disorder and Crime. Newbury Park, CA, Sage, 1993, pp 227-243.

3 1. MEDICALLY UNEXPLAINED SYMPTOMS

Ala~ M.Jacobson, M.D.

1. Define the term medically unexplained symptoms.

Patients commonly present to their primary physicians with medical symptoms that cannot be fully explained by specific somatic illnesses. Such unexplained symptoms may vary considerably in duration and severity; often they are transient and mild, resolving without specific intervention. Simple explanation and reassurance, supported by physician assessment (history, physical exam, and office-based laboratory tests), may significantly reduce others. The severity, intensity, and persistence of the symptoms dictate consideration of in-depth diagnostic evaluation, which may include more extensive medical and psychiatric work-ups. Even with detailed assessment, a clear somatic explanation may remain elusive, and the symptoms may persist. Four groups of psychiatric disorders comprise the more severe and/or persistent presentations of medically unexplained symptoms: somatoform disorders, factitious disorders, other psychiatric disorders (e.g., anxiety and depression), and malingering.When assessing patients with medically unexplained symptoms that are more than mild or transient, consider etiologies in all four spheres.

2. Do all severe andor persistent unexplained presentations have psychiatric causes? No. Some unexplained symptoms are due to biomedical syndromes that are not yet diagnosable.
Indeed, in the course of ongoing somatoform and other psychiatric disorders, patients may develop

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medical problems that require treatment. This scenario can be especially demanding when somatization occurs in the context of chronic medical illness. Thus the clinician must maintain a balance: helping the patient with underlying psychiatric problems while remaining attuned to unfolding medical conditions. Careful psychiatric assessment helps to identify classic patterns of psychopathology, which may guide the evaluator to consider the possibility of unrecognized medical conditions.

3. What are the common characteristics of somatoform disorders?

Somatoform disorders present with physical symptoms that are not fully explained by clear medical disorder, the effects of substance abuse, or other psychiatric syndromes. The physical symptoms are not intentional and not under voluntary control. There are five general categories: Somatoform Disorders
CATEGORY KEY CHARACTERISTICS
~

Somatization disorder

Conversion disorde1

Hypochondriasis

Body dysmorphic disorder Chronic pain syndrome

Multiple symptoms-pain, gastrointestinal,sexual dysfunction Symptoms vary over time Chronic condition-often with extensive treatment history Not intentional Symptoms affect voluntary motor or sensory system Symptoms do not conform to neuroanatomic structures May reflect, symbolically, past or current stressor Patient may not be upset by the symptoms Not intentional Chronic preoccupation with having a serious disease Patient misattributes symptom or test results Preoccupation not solely due to affective status Preoccupation with an imagined defect in physical appearance May exaggerate mild anomaly Pain is the central feature May begin after specific injury Can lead to serious functional impairment and medication overuse

4. Describe somatization disorder.

Previously somatization disorder was referred to as hysteria or Briquets syndrome. It is a chronic fluctuating condition that usually begins after the age of 30 and extends over many years. The patient presents with multiple symptoms, including pain, gastrointestiiial symptomatology, neurologic symptoms, and sexual dysfunction, which may vary considerably over time. He or she may have a long history of past extensive treatment, including surgery. Typically, the patient seeks out multiple providers because of dissatisfaction with prior treatment, and may end up on complex combinations of medications because of frustration on the part of both patient and physician. Significant impairments in work and social functioning are common. As described in the Diagnostic and Statistical Manual-N, patients should have a history of pain in at least four different sites: two different gastrointestinal symptoms other than pain, at least one sexual symptom, and one neurologic symptom. Symptoms vary in type and frequency across cultures and countries, and between genders. In North America, somatization disorder is more commonly found in women; up to 2% of women and less than 0.2% of men have a lifetime prevalence of this disorder.

5. What is revealed in the work-up of a patient with somatization disorder? The work-up of the patient with somatization disorder usually reveals a positive history of multiple medical and surgical treatments, current symptoms without abnormal laboratory test results, and a physical exam that fails to identify objective findings that explain subjective complaints. As with other patients with unexplained medical symptoms, past treatment may give rise to new symptoms, as well as clear physical findings. For example, the patient may have had an exploratory laparotomy, and as a result he or she now is experiencing persistent symptomatic cramping pain due to adhesions.

Medically Unexplained Symptoms 6. Describe conversion disorder.

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Conversion disorder presents with deficits of the voluntary motor or sensory neurologic system, and often mimics recognized neurologic or other medical conditions. As with somatization disorder, the symptoms are not intentionally produced; rather, underlying psychological factors are expressed in physical symptoms. Common presentations include loss of sensation in a single limb or part of a limb, double vision, blindness, deafness, difficulty with swallowing, and paralysis. On careful exam, the symptoms typically do not conform to recognized anatomic pathways. For example, a classic sensory loss due to conversion disorder may conform to a glove or stocking distribution. Recognize, however, that unusual distributions of sensory and motor loss can occur in some neurologic disorders, such as multiple sclerosis.
7. How are underlying psychological factors expressed physically in conversion disorders? Historically, conversion reactions have been thought to symbolize unresolved conflict. For example, the patient who feels guilt-ridden because he or she stole something loses all ability to move the hand that grabbed the object. Such conversion symptoms may occur in patients with a history of physical and emotional abuse or borderline personality disorder. Conversions disorders are likely to be associated closely in time with an acute stressor. However, the stressor itself may be mild and important only as a symbolic representation of past psychological trauma or conflict. For example, a patient who suffered oral rape may develop trouble with swallowing (sometimes called globus hystericus) on viewing a movie that depicts sexual violence. Most patients (but not all) do not concurrently remember the earlier event; gagging is felt without an accompanying memory of trauma or conflict.

8. Are these patients seeking pity and sympathy?

While reinforcing social responses may occur, the conversion disorder is thought to derive primarily from inner psychic gain. In the previous example (Question 7), the muffled ability to speak may represent the individuals earlier sense of suffocation and gagging as an abused child. The inner conflict also may have been caused by the authority figures threat to kill the patient if he or she told anyone and/or by the patients inner shame or guilt. Because the early event commonly is forgotten or poorly remembered and only the symbolic physical symptom is experienced, the patient with a conversion disorder may present with minimal upset. This reaction has been termed la belle indifference. In other instances, the patient may be confused and even terrified by the new symptom, even while having no anxiety about the actual trauma.

9. Describe hypochondriasis. Hypochondriasis refers to a chronic preoccupationwith and fear of having a serious disease. It typically is based on the individuals continual misperception of bodily symptoms and/or test results, and may occur in the context of a well-recognized and diagnosed illness, such as diabetes, or in the absence of known illness. The preoccupation persists despite all reasonable medical testing and reassurance; it may cover a wide range of body functions and systems over time as various evaluations demonstrate healthy functioning. Although the preoccupation cannot be attributed solely to the presence of comorbid anxiety, depression, obsessive-compulsive disorder, or psychotic disorder, it may be associated with these conditions. Hypochondriasis may occur at any age. The course is usually chronic, with waxing and waning symptoms and presentations. It seems to be equally common in men and women and may be made worse by the diagnosis of new medical problems.

10. What should the physician guard against in treating a hypochondriac? Hypochondriacs frequently doctor shop when dissatisfied by the responsivity of their current physician. Doctor shopping may occur in response to failure to diagnose a condition, but more commonly occurs when a physician unwittingly becomes irritated by the patients persistent complaints. Such irritation may manifest as avoidance behavior-failure to return phone calls, abrupt referral to a psychiatrist without careful preparation, or unwillingness to reassure the patient for the umpteenth time that the dark urine does not represent kidney failure.

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11. What is the treatment for hypochondriasis? Treatment of the hypochondriac should include careful assessment and reassessment for comorbid psychiatric disorders. Particularly important is aggressive treatment of symptomatic anxiety, depression, and frank delusions, which may worsen hypochondriacal complaints and/or occur in response to the chronic fear of disease. Although hypochondriasis and chronic somatization disorder should be considered as separate entities and are differentiated by the hypochondriacs intense preoccupation, in practice they exist on a continuum.

12. How does hypochondriasis differ from body dysmorphic disorder?

Hypochondriasis does not focus on a specific, circumscribed concern about appearance (see Question 13).

13. Describe body dysmorphic disorder. Body dysmorphic disorder refers to preoccupation with an imagined defect in physical appearance. The sense of defect may occur in response to a mild physical anomaly or with no identifiable trace of abnormality. A common example is the person obsessed with the ugliness of his or her nose because of a small bump. Distress frequently leads to a search for cures through techniques such as plastic surgery or dental treatment. The patient frequently is tormented with feelings of inadequacy and may go to extreme lengths to resolve them; make-up, exercise, and diet may be part of important rituals. Clearly, the intense focus of western culture on physical beauty provides a setting for a continuum of concern about bodily perfection. Body dysmorphic disorder represents an extreme of this continuum. In anorexia nervosa the focus is on being too fat; thus, the patient uses diet-related methods rather than surgery to cure the problem.
14. Describe pain disorders. Pain disorders are characterized by a specific, predominant focus on pain as the presenting symptom. The pain usually does not follow established anatomic patterns. However, it may be impossible to differentiate from established medical conditions such as lumbar disc disease. Although work-ups typically are negative, prior invasive treatment may lead to physical findings that completely muddy the diagnosis (see Question 5). Indeed, pain disorders may develop after prior injury or treatment, which provides some pathophysiologic explanation for the symptoms. Pain disorders may occur throughout the lifespan and are more common in women than men. The course may be persistent and lead to severe functional impairment and extensive use of pain medication. 15. How are pain disorders assessed and treated? Pay careful attention to the presence of comorbid depression, which may present with pain symptoms. Psychotic and anxiety disorders also may feature pain, as one of an array of symptoms. The management of chronic pain syndromes is described at length in Chapter 69. Rehabilitation programs combining behavioral and physical therapies may be helpful in some patients. External gains (e.g., social, financial) may affect the success of treatment, but as with somatization disorder, the primary cause is inner psychic gain.

16. Describe malingering. The essential feature of malingering is an intentional causing or faking of physical or psychological symptoms motivated by external incentives. Such incentives may be monetary or related to avoidance of work, prosecution, or military service; they also may involve the goal of obtaining drugs. Several factors are suggestive of underlying malingering. Most commonly, the symptom is complex a d o r vague, and the patient is involved in a law suit because of an injury or accident. The discrepancy between the symptomatic presentation and the apparent physical findings may be marked. Lack of cooperation in the evaluation process and poor compliance with recommended treatment are also common. Finally, the presence of an antisocial personality disorder may suggest malingering in a patient presenting with unexplained symptoms associated with possible external rewards or motivations. Thus malingering, unlike somatoform disorders, is motivated primarily by external gain.

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17. Describe factitious disorder. In factitious disorder, external factors may be present, but they play a minor role in providing support or reinforcement for symptoms. The motivation for a factitious disorder appears to derive from assuming the role of a sick person. Factitious disorders may involve fabrication of subjective complaints, such as headache; self-inflicted injury; and/or exaggeration of pre-existing medical conditions. Patients with factitious disorder usually engage in some form of lying. They may present with vague, inconsistent histories, often with a dramatic flair. Patients often have prior experience with medical routines and are knowledgeable about medical terminology. They eagerly await work-up results, and their complaints may change with normal or negative findings. They even ask for multiple invasive procedures. Patients usually deny any suggestion that symptoms are self-induced or exaggerated and upon confrontation usually discharge themselves, only to appear in another emergency department or clinic. The onset of factitious disorder is usually in adolescence or early adulthood. Although it may involve only a few episodes, chronic patterns often develop; in some instances, the patient travels to multiple cities-even countries-seeking hospitalization.
18. What is Miiuchausens syndrome? An extreme form of chronic, recurrent factitious disorder that typically involves wandering from place to place and taking on a lifestyle that centers on repeated evaluation, treatment, and hospitalization. The extensive wandering and search for different treatments may result from confrontations by angry hospital staff. However, it is not entirely clear whether the wandering and the accompanying disorder can be prevented by alternative treatment approaches. Severe factitious disorders also have been described in children. The parent reports symptoms in the child in the manner described in adults. Termed Miinchausens by proxy (see Chapter 81), this syndrome should be considered as a possible instance of child abuse and reported to appropriate authorities under the guidance of state and local laws.

19. How are malingering and factitious disorder distinguished from somatoform disorders? Malingering Factitious Disorder Motivated by assumption of the sick role Motivated by external gain (e.g,. winning Symptoms fabricated andor injury a lawsuit) Symptoms intentionally caused or feigned self-inflicted Poor cooperation in evaluation and History vague and confusing treatment Often chronic May be accompanied by antisocial Patients may go from hospital to hospital personality disorder seeking care Somatoform Disorders Motivated by inner, psychic gain Unintentional, involuntary May be result of past or current, traumatic stressor

20. Describe a general approach to the patient with unexplained medical symptoms. The management of unexplained medical symptoms is a series of recurring steps. In the acute presentation, careful assessment of the medical symptoms, physical findings, and associated psychological responses may be followed by thoughtful, nonjudgmental reassurance when the symptoms are relatively mild, circumscribed, and of recent origin. The psychoeducational approach (information, reassurance, and explanation of probable cause) is often sufficient, and the symptoms remit. For example, a child may present with headaches before school is to begin. Exploration of the stress may help the parents and child to find methods of reassurance that alleviate the source of the anxiety-based symptoms. Such an approach can be used in combination with more in-depth medical assessment. For example, a patient hospitalized for treatment of a compound fracture of the left leg spontaneously de-

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veloped paresis in the good leg. The paresis appeared to have no anatomic basis. Assessment by a consulting neurologist confirmed the initial evaluation by the primary physician. The consultants suggestion that the symptoms would improve gradually over time was sufficient; over the following several days of recuperation the symptoms completely remitted. When symptoms are persistent and/or severe, further steps are warranted, including more medical evaluation and detailed psychosocial assessment to identify psychological factors and social triggers. The laboratory and physical findings should be presented unambiguously and in a nonjudgmental manner. The treatment plan may require negotiation with the patient to set limits on the nature of investigations, specialty referrals, and unwarranted treatment. Avoid simplistic dual models in which the diagnosis is either physical or mental. Present, as part of the medical evaluation, a psychological explanatory model of the symptom process using words that are both understandable and safe. The model can indicate that the symptoms may be stress-related.

21. Wont the patient balk at any suggestion that symptoms are stress-related? Sometimes; but the approach recommended can improve patient acceptance. As one part of this approach, underline that stress-related symptoms are just as real as symptoms produced by a clear
medical illness. For example, the patient fearing cancer needs to understand that the presenting symptom, if it is said to be stress-related, is just as important to you a5 if it were caused by cancer. Furthermore, emphasize that the suggested treatments for somatoform disorders are just as real as treatments for feared medical conditions, though they differ. Careful assessment also should include evaluation for comorbid psychiatric conditions such as depression, anxiety, personality disorders, and psychosis. It is helpful to have a single medical doctor or team approach in treating the chronic somatisizing patient. The team may include a physician and a mental health professional who work either in the same institution or in close collaboration. Be open and honest at all steps of the treatment. Sneaking in a psychiatric referral leads only to greater mistrust and resistance to treatment recommendations.

22. How can the physician facilitate the process?

Consistency and flexibility are both important. Avoid unnecessary, new medical assessments. Offer a clear, sensible, and consistent pronouncement of your findings and recommendations. Patients often need to hear repeatedly what the doctor thinks, why he or she thinks it, and why a specific treatment is or is not recommended. At times of increased anxiety, flexibility may be required. For example, the patient who is chronically womed about renal failure may require periodic (and superficially unnecessary) simple kidney function tests to demonstrate kidney health. Letting the patients concerns help to dictate evaluation and treatment decisions provides a sense of control. Continual renegotiation with the patient is essential. Flexibility also is warranted because in the course of chronic somatisizing problems other psychiatric disorders commonly develop (e.g., the hypochondriac may require antidepressant treatment). Likewise, inflexibility may lead to missing the diagnosis of newly emerging medical illness. Finally, by maintaining a consistent, stable, nonjudgmental attitude the physician helps patients to feel understood, encouraging continuation of treatment and avoiding doctor shopping.

23. Are specific treatment approaches applied differentially to the different forms of somatoform disorders? There are more similarities than differences in treating patients with medically unexplained symptoms. As noted, the severity and chronicity of the complaint are important determinants of the initial approach. Additionally, certain therapeutic variations derive from the type of somatoform disorder. Patients with body dysmorphic disorder may benefit from a supportive therapeutic approach that helps the patient to understand possible sources of the distorted beliefs. Cognitive-behavioral therapy may be useful (see Chapter 41). Beliefs about body shape and deformity are so powerful, however, that short-term cognitive approaches are unlikely to lead to radical improvement. Thus, they should be considered in the context of chronic management that helps the patient to avoid recuiTent, invasive treatment. The distorted perceptions can be so severe as to become delusional; such patients may respond to low doses of antipsychotic medication.

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A focused approach is less likely to be effective in somatization disorder and hypochondriasis because of the broad range of symptoms and complaints. In all instances the therapy for chronic conditions needs to be considered as long-term and supportive. Recognition of serious underlying psychological problems may not only guide therapy but also serve to allay the doctors sense of being used and abused by the patient, thereby helping to maintain a positive therapeutic alliance. Especially in patients with conversion disorder, hypnotherapy and/or other methods for exploring sources of particular stress may bring out unresolved conflicts and concerns that were not previously identified. Uncovering such issues can be useful in treating conversion symptoms.

24. What is especially important to remember in caring for patients with medically unexplained symptoms? The therapist and physician must recognize that these patients often produce intense emotional reactions in the caretaker. They may arouse anger by repeated complaints and disturbances as well as cause embarrassment with multiple visits to the emergency department, seeming to represent treatment failures in the eyes of the clinician and possibly his or her colleagues. Furthermore, chronic demands for pain medications and letters to housing boards and employers may lead the clinician to feel used by the patient. Remember that while external gain may be a secondary motivation for some symptoms in some patients, it is usually not the primary causal factor.
25. How do approaches to treatment differ for patients with factitious disorder or malingering? In many ways the approaches to treatment are similar. The critical differential with the malingering patient is recognizing that the patient always has another, external goal; consistency and clarity are required so that the patient understands what the physician is recommending. Many such patients leave treatment because they do not obtain an external reward. The patient with factitious illness also may leave treatment if the drive for the sick role comes in conflict with the physicians unwillingness to perform more invasive tests.
26. How are medical symptoms associated with other psychiatric conditions differentiated from those associated with somatoform and factitious disorders and malingering? Three psychiatric syndromes most commonly present with subtle and sometimes vague physical symptoms: depression, anxiety, and psychosis. Diagnosis depends on a careful history that explores for the symptoms of each psychiatric disorder. When the patient presents with symptoms suggestive of either anxiety or depression, such as headaches or other bodily pains, a trial of appropriate medication may be useful. Such therapeutic trials are also valuable because anxiety and depressive disorders may well coexist with somatoform conditions. Treatment of the comorbid psychiatric condition may lead to considerable improvement in the somatoform disorder. In addition, symptomatic treatment of depression, anxiety, and psychosis often is more effective than treatment of chronic somatisizing conditions.
BIBLIOGRAPHY
1. Bass C, Benjamin S: The management of chronic somatisation. Br J Psychiatry 162:472480, 1993. 2. Reference deleted. 3. Kellner R: Psychosomatic syndromes, somatization and somatoform disorders. Psychother Psychosom 61:4-24, 1994. 4. Kellner R: Somatization: Theories and research. J Nerv Mental Dis 178:15&160, 1990. 5. Lipowski ZJ: Somatization: The concept and its clinical application. Am J Psychiatry 145:1358-1368, 1988. 6. Margo KL, Margo GM: The problem of somatization in family practice. Am Fam Physician 1873-1 879, 1994. 7. Mayou R: Somatization. Psychother Psychosom 59:69-83, 1993. 8. Somatoform disorders. Diagnostic and Statistical Manual-IV. Washington, DC, American Psychiatric Association, 1994. 9. Wise MG, Ford CV: Factitious disorders. Prim Care 26:315-326, 1999.