Malingering, factitious disorders and somatoform disorders: Pathology review

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Case study0:00–1:15

A 5 year old girl named Celia is brought to the emergency department by her mother due to a sudden episode of loss of consciousness.
You decide to run some blood tests, which reveal low glucose levels. After glucose administration, Celia fully recovers.
You admit her to the hospital to do exhaustive studies to start looking for a cause of her hypoglycemia. The tests all come back normal, so you decide to discharge Celia.
The next morning, Celia has another unexplained episode of hypoglycemia, so you decide to check her blood insulin levels, which are found high, while her C-peptide levels are slightly low.
Some days later, 32 year old Sofia presents to the emergency department. Sofia is complaining of severe chest pain that has been going on for the past couple hours, and she is certain that she is having a heart attack.
According to the hospital records, she has presented to the emergency department with similar symptoms 7 times within the past 12 months.
And each time, cardiac evaluation was normal. Upon examination, both cardiac auscultation and ECG are normal.
Sofia becomes frustrated and storms out of the hospital demanding a second opinion. Based on the initial presentation, both Celia and Sofia have some form of malingering, factitious, or somatic symptom and related disorders.

Pathology1:15–1:33

What all these have in common is that the affected individual claims to have physical or psychological symptoms that aren’t explained by any known physical or mental disorder.Okay, starting with malingering, this is when individuals are intentionally faking or exaggerating their symptoms in order to achieve some secondary gain or external goal.

Malingering1:33–2:12

This may include getting money, housing, time off from work, access to medications, or even escaping jail time. In other words, they’re conscious or aware of their specific motivation.
For your exams, remember that these individuals are typically uncooperative, meaning that they demand an extensive workup, but are not satisfied with negative results and don’t adhere to the diagnostic follow-up or treatment plan.
Another clue is that symptoms stop once they achieve their goal.On the other hand, in factitious disorder, the individuals are intentionally faking or inducing symptoms, but the goal here is to get the attention and sympathy that is often given to someone who’s sick.

Factitious disorder2:12–4:00

And remember that these individuals are usually unconscious or unaware of their motivation, which means that individuals often don’t even realize why they fabricate their symptoms.
Now, there’s factitious disorder imposed on self, and factitious disorder imposed on another. In factitious disorder imposed on self, formerly known as Munchausen syndrome, individuals mainly pretend to have physical signs and symptoms of a disease.
This is most common in those with healthcare experience, such as healthcare workers or those somehow related to one, which makes them very knowledgeable about the symptoms they are trying to pass off as real.
And that’s an extremely high yield fact! For your exams, keep in mind that these individuals typically have a medical record of recurrent hospitalizations, and are overeager to go through invasive interventions, like surgical procedures.
But an important difference with malingering is that, in factitious disorder imposed on self, the pretend symptoms persist even after they get the attention, sympathy, or even medical care.In contrast, there’s factitious disorder imposed on another, formerly known as Munchausen syndrome by proxy.
In this case, the person deliberately makes a second person ill without that person’s knowledge. Often, this second person is someone they’re responsible for, like a child, an elder, or even a pet.
Remember that this is considered a type of child or elder abuse. And if that is suspected, it’s the healthcare provider’s responsibility to contact child or elder protective services.
Oftentimes a social worker should be involved to help decide on the best next steps to ensure the individual’s safety, like separating them from the abuser and helping the family cope.Now, make sure you don’t confuse this with vulnerable child syndrome, which is when a parent believes that their child is unrealistically prone to getting ill or injured.

Vulnerable child syndrome4:00–4:29

For your exams, keep in mind that vulnerable child syndrome classically starts after the child goes through a serious disease or life-threatening event.
And it may lead to repeated absences from school or exaggerated use of healthcare services.Now, remember that these (pause) are all intentional.
So switching gears, there’s somatic symptom and related disorders, where individuals are unintentionally experiencing symptoms that can’t be explained by any physical or mental disorder.

Somatic symptom & related disorders4:29–4:55

In other words, affected individuals truly believe their symptoms are real, which are often made worse because they can’t be medically explained or treated.
The most high yield somatic symptom and related disorders are somatic symptom disorder, illness anxiety disorder, and conversion disorder.Somatic symptom disorder is the one examiners love the most.

Somatic symptom disorder4:55–5:52

So learn by heart that individuals with somatic symptom disorder experience at least one unexplained physical symptom, called somatic symptom, for a period of at least 6 months.
These symptoms can be incredibly varied, including anything from pain to gastrointestinal problems or even sexual symptoms.
Another important fact is that these individuals constantly think about the seriousness of their symptoms, and get really anxious about their health.
For example, these individuals might feel a mild abdominal pain and spend hours thinking that they have cancer. In addition, they may devote excessive time and energy to their health concerns, which can sometimes interfere with the person’s ability to perform important activities, such as work, school activities, or family and social responsibilities.
Remember that these individuals often self diagnose themselves and do not trust the physician's diagnosis. Moving on, illness anxiety disorder occurs when individuals are excessively worried about having or developing a serious disease for at least 6 months.

Illness anxiety disorder5:52–6:33

Once again, they experience a lot of anxiety about their health, and spend too much time and energy obsessing over the possibility of developing a disease.
But what sets it apart from somatic symptom disorder is that, individuals with illness anxiety disorder don’t experience somatic symptoms, or only minimal ones.
Another clue is that individuals perform excessive health-related behaviors like repeatedly checking their body for signs of illness, or, alternatively, they avoid situations that make them confront their illness like medical appointments and hospitals.

Conversion disorder6:33–7:12

Finally, there is conversion disorder, also known as functional neurological symptom disorder. This involves one or more neurological symptoms related to voluntary movement or sensory function like sight and hearing, that are not explained by any neurological or medical condition.
For example, one might feel like they’re unable to move their legs only when they are at school, but have no trouble when they’re home.
This is typically triggered by a stressful event, physical or emotional trauma, and is more common among teenagers, or young adults.
The biggest clue here is known as la belle indifference, which is when individuals often appear extremely calm and indifferent when describing their symptoms.

Review7:12–8:25

All right, as a quick recap. Imagine a test question about an individual who’s dealing with physical or psychological symptoms that aren’t explained by any physical or mental disorder.
Malingering would be if they are intentionally faking these symptoms with a conscious motivation to achieve some secondary gain.
On the other hand, factitious disorder would be if they are intentionally faking symptoms, but without a conscious motivation, so even when there’s nothing to gain from it.
And this can be imposed on self, or imposed on another, most often a child or elder. Don’t confuse this with vulnerable child syndrome, where parents believe that their child is at an extreme risk of getting ill or injured, and usually occurs after a life-threatening event.
Okay, now, somatic symptom and related disorders involve an individual who’s unintentionally experiencing symptoms that aren’t real.
With somatic symptom disorder, the individual has at least one somatic symptom, associated with constant thoughts and excessive anxiety related to their health.
In illness anxiety disorder, there’s an excessive preoccupation with having or developing a serious disease. Finally, with conversion disorder, individuals experience unexplained neurological symptoms, often triggered by a stressful event and accompanied by “la belle indifference”.
Okay, back to our cases. Celia is a 5 year old girl that is brought in by her mother after an episode of loss of consciousness.

Summary8:25–9:37

This is probably related to the fact that she has hypoglycemia, which improved after glucose administration. An important clue is that despite exhaustive studies, no cause of hypoglycemia is found, which should already be a red flag for factitious disorder imposed on another.
The next morning, Celia has another unexplained episode of hypoglycemia. This, along with the high blood insulin levels but low C-peptide, which remember should normally be found in equal amounts to insulin, should make you suspect that the mother is inducing hypoglycemia on Celia by injecting exogenous insulin.
So, that’s a case of factitious disorder imposed on another, which means that you should contact child protective services immediately.
After Celia, you see 32 year old Sofia, who presents with chest pain and is convinced that she's having a heart attack. However, an important clue is that both cardiac auscultation and ECG are normal.
The most important clue is that she has repeatedly presented with the same unexplained symptoms, combined with the fact that she doesn’t get convinced by the negative workup.
So this is a classic case of somatic symptom disorder.