Somatoform and Factitious Disorders Review of Psychiatry Series John M. Oldham, M.D. Michelle B. Riba, M.D., M.S. Series Editors No. 3 Washington, DC London, England Somatoform and Factitious Disorders EDITED BY Katharine A. Phillips, M.D. Note: The authors have worked to ensure that all information in this book concerning drug dosages, schedules, and routes of administration is accurate as of the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice advance, however, therapeutic standards may change. For this reason and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of a physician who is directly involved in their care or the care of a member of their family. A product’s current package insert should be consulted for full prescribing and safety information. Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association. Copyright © 2001 American Psychiatric Publishing, Inc. 04 03 02 01 4 3 2 1 ALL RIGHTS RESERVED Manufactured in the United States of America on acid-free paper First Edition American Psychiatric Publishing, Inc. 1400 K Street, NW Washington, DC 20005 www.appi.org The correct citation for this book is Phillips KA (editor): Somatoform and Factitious Disorders (Review of Psychiatry Series, Volume 20, Number 3; Oldham JM and Riba MB, series editors). Washington, DC, American Psychiatric Publishing, 2001 Library of Congress Cataloging-in-Publication Data Somatoform and factitious disorders / edited by Katharine A. Phillips. p. cm. — (Review of psychiatry ; v. 20, no. 3) Includes bibliographical references and index. ISBN 1-58562-029-7 (alk. paper) 1. Somatoform disorders. 2. Factitious disorders. 3. Medicine, Psychosomatic. I. Phillips, Katharine A. II. Review of psychiatry series ; v. 20, 3 [DNLM: 1. Somatoform Disorders. 2. Factitious Disorders. WM 170 S6927 2001] RC552.S66 .S676 2001 616.89—dc21 00-067403 British Library Cataloguing in Publication Data A CIP record is available from the British Library. Cover illustration: Copyright © 2001 David Williams/Illustration Works. Contents Contributors ix Introduction to the Review of Psychiatry Series xi John M. Oldham, M.D., and Michelle B. Riba, M.D., M.S., Series Editors Foreword xv Katharine A. Phillips, M.D. Chapter 1 Somatization Disorder 1 Vicenzio Holder-Perkins, M.D. Thomas N. Wise, M.D. Evolution of Diagnostic Criteria 2 Epidemiology 7 Clinical Features 8 Etiologic Considerations 9 Differential Diagnosis 12 Evaluating the Patient with Somatization Disorder 13 Treatment Considerations 16 Conclusion 20 References 21 Chapter 2 Hypochondriasis 27 Brian A. Fallon, M.D. Suzanne Feinstein, Ph.D. Clinical Features 28 Theoretical Models 31 Treatment of Hypochondriasis 43 Conclusion 59 References 60 Chapter 3 Body Dysmorphic Disorder 67 Katharine A. Phillips, M.D. History 67 Prevalence 68 Clinical Features 69 Etiology and Pathophysiology 76 Relationship With Other Disorders 76 Diagnosis 80 Treatment 81 Conclusion 88 References 88 Chapter 4 Conversion Disorder 95 José R. Maldonado, M.D. David Spiegel, M.D. Clinical Subtypes 97 History 101 Models of Symptom Generation 106 Functions Served by Conversion Symptoms 109 Associated Features 110 Epidemiology, Demographic Features, and Disease Course 111 Comorbidity 114 Differential Diagnosis 115 Treatment 117 Conclusion 121 References 121 Chapter 5 Factitious Disorder 129 Marc D. Feldman, M.D. James C. Hamilton, Ph.D. Holly N. Deemer, M.A. Epidemiology and Etiology 130 Diagnosis 133 Clinical Description 134 Associated Features 139 Prevalence 140 Costs 145 Limitations of Current Approaches 146 Etiology 149 Management 152 Conclusion 157 References 159 Afterword 167 Katharine A. Phillips, M.D. Index 169 Contributors ix Contributors Holly N. Deemer, M.A. Doctoral Candidate in Clinical Psychology, Department of Psychology, University of Alabama, Tuscaloosa, Alabama Brian A. Fallon, M.D. Associate Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York; Director, Somatic Disorders Treatment Program, New York State Psychiatric Institute, New York, New York Suzanne Feinstein, Ph.D. Research Psychologist, New York State Psychiatric Institute, New York, New York Marc D. Feldman, M.D. CPM Medical Director; Vice Chair, Clinical Services; and Associate Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, Alabama James C. Hamilton, Ph.D. Assistant Professor, Department of Psychology, University of Alabama, Tuscaloosa, Alabama Vicenzio Holder-Perkins, M.D. Instructor, Department of Psychiatry, Georgetown University School of Medicine, Washington, D.C.; Instructor, Department of Psychiatry, George Washington University School of Medicine, Washington, D.C. José R. Maldonado, M.D. Assistant Professor of Psychiatry; Medical Director, Consultation/ Liaison Psychiatry; and Chief, Medical and Forensic Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California John M. Oldham, M.D. Dollard Professor and Acting Chairman, Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York x SOMATOFORM AND FACTITIOUS DISORDERS Katharine A. Phillips, M.D. Associate Professor of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island; Associate Medical Director, Ambulatory Care, and Director, Body Dysmorphic Disorder Program, Butler Hospital, Providence, Rhode Island Michelle B. Riba, M.D., M.S. Associate Chair for Education and Academic Affairs, Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan David Spiegel, M.D. Professor of Psychiatry; Director, Psychosocial Treatment Laboratory; and Director, Complementary Medicine Clinic, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California Thomas N. Wise, M.D. Professor, Department of Psychiatry, Georgetown University School of Medicine, Washington, D.C.; Professor, Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland; Medical Director, Behavioral Services, Inova Health Systems, Falls Church, Virginia [...]... mysteries of these disorders Despite the consistent richness of their historical and clinical tradition, somatoform and factitious disorders have received variable, and in some cases limited, empirical investigation One xvi SOMATOFORM AND FACTITIOUS DISORDERS exception is somatization disorder For decades researchers have applied an unusually careful and systematic approach to developing and refining the... patients to seek psychiatric help xiv SOMATOFORM AND FACTITIOUS DISORDERS Foreword Katharine A Phillips, M.D The somatoform and factitious disorders are fascinating syndromes that are beset with contradictions They have an unusually long, rich, and colorful historical and clinical tradition, yet some of them have received scant empirical investigation Most of the somatoform disorders appear to be relatively... dissociative disorders and should be classified with them, as in ICD-10 On the other hand, conversion disorder also appears to be related to certain somatoform disorders, particularly somatization disorder and pain disorder The chapters that follow offer a broad and scholarly synthesis of much of the current knowledge, as well as current controversies, about somatoform and factitious disorders They... pseudoseizures, for example), the somatoform disorders may go unrecognized or be diagnosed incorrectly The factitious disorders appear to be more common in medical settings than is generally appreciated, and they are among the most memorable and difficult cases that clinicians encounter Most of the chapters in this book convey the unusually rich history of somatoform and factitious disorders The intriguing... by Harold Sackeim regarding late-life depression Certain conditions, such as the somatoform and factitious disorders, can baffle even our most experienced clinicians As Katharine Phillips points out in her foreword to Somatoform and Factitious Disorders, these disorders frequently go unrecognized or are misdiagnosed, and patients with these conditions may be seen more often in the offices of nonpsychiatric... is also excluded Although factitious disorders are classified in a separate section of DSM-IV-TR, they are included here because they often consist of prominent somatic symptoms, and in clinical settings they can be difficult to differentiate from the somatoform disorders Indeed, as discussed in Chapter 5, the somatoform disorders and factitious disorder may not be discrete and distinct, but may instead... referral note describing the disorder and explaining 16 SOMATOFORM AND FACTITIOUS DISORDERS that such individuals tend to use a disproportionate amount of health care services and undergo unnecessary tests, procedures, and surgeries This study was impressive in its efficient intervention and robust outcome Direct attention to comorbid conditions, such as depression, anxiety, and substance abuse, is also essential... primary care, and specialty medical settings—yet they often go unrecognized and undiagnosed In addition, although the somatoform disorders are grouped together in a separate diagnostic section of DSM-IV-TR, they are unlikely to be closely related The somatoform disorders somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic... DSM-IV somatoform disorders The somatoform disorder section in DSM-IV reflects disorders in which somatic complaints are central issues as opposed to merely unexplained physical symptoms or other applications of the concept of somatization The somatoform disorders include not only somatization disorder, but also hypochondriasis, undifferentiated somatoform disorder, conversion disorder, pain disorder, and. .. disorder, and elegant family and adoption studies have been conducted Research on hypochondriasis has delineated its phenomenology, comorbidity, and assessment, greatly advancing our understanding of the disorder Although systematic research on BDD has only recently begun, our knowledge of this underrecognized disorder has rapidly increased during the past decade Treatment of the somatoform and factitious disorders . Somatoform and Factitious Disorders Review of Psychiatry Series John M. Oldham, M.D. Michelle B. Riba, M.D., M.S. Series Editors No. 3 Washington, DC London, England Somatoform and Factitious. Authoritative and reliable guides to help the consumer differentiate between sound advice and unsubstantiated opinion are hard to come by, xii SOMATOFORM AND FACTITIOUS DISORDERS and our patients and their. paper) 1. Somatoform disorders. 2. Factitious disorders. 3. Medicine, Psychosomatic. I. Phillips, Katharine A. II. Review of psychiatry series ; v. 20, 3 [DNLM: 1. Somatoform Disorders. 2. Factitious