198 - Conversion Disorder, Psychosomatic Illness, and Malingering

Somatization disorder is characterized by the presence of multiple chronic distressing somatic symptoms that are not medically explained. Patients with this condition tend to be highly anxious about their symptoms, even in the face of evidence that their condition is not medically serious. In the draft of the upcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-V), this condition has been renamed CSSD. Hypochondriasis is preoccupation with or excessive fear of illness despite negative testing and reassurance from a health care professional. Hypochondriasis is more common than somatization disorder and has a prevalence of 4% to 9% in general medical practice. It peaks in men in the fourth decade and in women in the fifth, with no significant predilection by gender. Hypochondriasis is increasingly being described in geriatric populations. It has been renamed the “predominant health anxiety” subtype of CSSD in the proposed draft of DSM-V. Somatoform pain disorder, an important and particularly challenging somatoform illness, is characterized by somatoform symptoms that are manifested predominantly as pain. In the proposed draft of DSM-V, this condition is reclassified as the “predominant pain” subtype of CSSD. Conversion disorder is a condition in which patients complain of sensory or motor symptoms as a manifestation of stress or unconscious conflict that cannot be attributed to a pathophysiologic process. Conversion disorder is more common in women and members of lower socioeconomic groups. Its onset typically begins in adolescence, and it follows a discontinuous course. Conversion disorder has also been observed in military, mass casualty, and industrial accident settings without a female preponderance of the disorder. Estimates of prevalence vary considerably as a result of inconsistent classifications and definitions of the disorder. • Somatization disorder, conversion disorder, and hypochondriasis are psychologic reactions to stressful circumstances that are neither intentional nor planned. • Malingering and factitious disorders involve deliberate actions of deceit of which the patient is aware. • Somatoform conditions feature complaints and symptoms that cannot be attributed to medical illness. • Emergency department evaluation of patients with suspected somatoform disorders should focus on the search for a medical cause of the reported symptoms and exclusion of life-threatening illness. • Identification and appropriate referral of patients with somatoform illness are secondary objectives of the emergency department encounter. • As with other psychiatric and medical diagnoses, thorough documentation is required when somatization is suspected. KEY POINTS