Psychological Factors Affecting Other Medical Conditions

00:00 Now let’s move on to talk about Psychological Factors Affecting Other Medical Conditions. So, psychological factors affecting other medical conditions is diagnosed when a general medical condition is adversely affected by psychological or behavioral factors. The factors may precipitate or exacerbate the medical condition, interfere with treatment, or contribute to a patient's morbidity and mortality. Now, let’s take a look at factitious disorders and consider this case example, which is a nice illustration of a factitious disorder. "A 30-year-old nurse has been passing out at work lately and her colleagues had to rush her to the emergency room. The nurse has no past history of medical problems and appears very concerned, fearful while she’s in the emergency room and she is extremely appreciative to all of the doctors and nurses and staff who are taking care of her. She asks that they check in on her intermittently and when they do she’s profusely appreciative. Her vital signs are concerning. Her blood pressure is extremely low and she’s tachycardic. Her blood glucose level is down to 20. The emergency room team stabilized her and an orderly observes later that the nurse is actually injecting herself with something that she has taken out of her purse. The vial is later found and identified to have insulin in it." So, factitious disorder is when patients will intentionally produce medical or psychological problems in an effort to become the patient, to assume a sick role. It’s called primary gain. Some statistics about factitious disorder are that it occurs in about 5% of hospitalized patients and it’s actually a little bit more common in men. There is a higher incidence in hospitals and healthcare workers, and it’s associated in fact with higher intelligence, a poor sense of identity and poor sexual adjustment. Many patients with a history of childhood abuse or neglect will be affected and this is because inpatient hospitalization probably provided some sort of a refuge from the abused child and so they grow up kind of being comfortable in that role of the sick patient because they actually get some appropriate attention and they're cared for. This though can lead to a slippery slope of lots of repeated and long-term hospitalizations.

02:37 So, going back to our case study with this woman, the nurse, who is injecting herself with insulin.

02:43 So, that’s a classic example of a factitious disorder. She is doing something in an effort to assume a sick role, and you diagnose it by looking at the following criteria: It’s the intentional faking of symptoms in order to be sick. There are no external benefits other than becoming a patient and being cared for. Factitious disorder patients tend to have some medical knowledge, so remember that case study of the nurse, she probably knew that giving herself insulin will lead to a hypoglycemic crisis and she would end up getting a lot of medical attention and help.

03:21 So, common presentations include things like bleeding, infections, hypoglycemia, etc. Patients will often give a vague and inconsistent story to their healthcare provider and there are usually multiple different providers involved in their care and when challenged about the validity of their ailments, the patient will often leave that doctor and just go find another provider.

03:49 Something else worth knowing about is Munchausen syndrome. So this could come up on your exam, so let’s take a moment to talk about it. Munchausen syndrome is an extreme presentation of factitious disorder. So, here, patients feign a disease and move from hospital to hospital.

04:07 They submit themselves to repeated invasive procedures and offer an illness that they have voluntarily manufactured. There’s also something called Munchausen syndrome by proxy and this is very serious. This is actually when a parent will inflict some sort of medical illness on their child. Also, their child can be the sick patient and then the parent gets some gain out of that by accompanying their child to various hospitals and providers and being a caretaker. So, this is also something that can sometimes come up on exams and worth knowing about. When it comes to factitious disorder, there’s really no effective treatment. It’s important to diagnose it accurately to make sure you’ve ruled out actual medical problems and when you are suspecting a factitious disorder, you want to try to avoid unnecessary procedures or tests. And also an important note is to consolidate care amongst providers so that there isn't as much fracture amongst the patient care. So, when it comes to treatment of somatization or somatic symptom disorders, the best treatment occurs in the context of really forming a long-term relationship with the patient and usually this will be through a primary care provider. They’ll often schedule regular routine followups , they avoid a struggle with the patient, they set the agenda for the meeting, they do no more and no less for the somatic patient than they would for any other patient, they set limits and they really introduce the idea of psychosocial issues very slowly.

05:49 The goal in treating factitious disorder is really to provide care, not to focus on a cure, and a psychiatric referral can be useful when a patient will actually endorse that they are having some comorbid issue like extreme anxiety or depression and that can be a nice gateway to introducing a psychiatrist in the care. Let’s talk about hypochondriasis now. Consider this case example. "A 23-year-old woman is convinced that she has breast cancer but there is no family history. But given her concerns, her doctor does go ahead and complete a breast exam, which is completely normal. Her doctor orders blood work, which is all normal, and the patient undergoes an ultrasound scan of her breasts, which is also normal. So, everything is very reassuring for this young, 23-year-old woman with no symptoms and no abnormal work-up. So the patient was reassured but later she starts to worry again. She goes back to her doctor and asks for a mammogram but when the doctor recommended that the woman seek out a therapist to explore her fears, the patient became angry and said she’d just go get a second opinion." So, hypochondriasis is the prolonged and exaggerated concern about health and possible illness. Patients fear having a disease or are convinced that they have a disease. They misinterpret normal bodily symptoms as an indicator that in fact they’re quite sick. Men are affected more than women and it tends to occur in 20 to 30-year-olds and about 80% of patients will have a coexisting major depression or anxiety disorder. You must absolutely rule out any general medical conditions or organic causes of the illness that the patient is worried about before labeling it as hypochondriasis. So, what’s the difference between somatization and hypochondriasis? Well, in somatization, patients will worry about their symptoms. In hypochondriasis, patients will worry about the actual disease. So, remember our case study of the woman who feared she has breast cancer. That’s a pretty classic example of hypochondriasis. There are no signs that she could have this and yet she is fixated on the disease despite having no symptoms. So to treat hypochondriasis, she should acknowledge that there’s really no cure but you want to manage the individual usually through routine primary care visits who is going to be the doctor overseeing the management of this patient. Often, individuals are reluctant to go into therapy although what could be helpful would be some kind of group therapy or even insight-oriented therapy with a one-to-one therapist.