A 40-year-old woman has had multiple tests done for her symptoms of abdominal pain, including abdominal CT, colonoscopy, pelvic ultrasound and laparoscopy. All tests have been normal. Despite assurance she still is continually scared that she may have something serious.
Which of the following disorder does she likely have?
Correct Answer E:
Hypochondriasis is a fear of having a serious disease based on misinterpretation of physical symptoms or normal bodily functions. Hypochondriasis is nonvolitional; the exact cause is unknown. Diagnosis is confirmed when fears and symptoms persist for ≥ 6 months despite reassurance after thorough medical evaluation. Treatment includes establishing a consistent, supportive physician-patient relationship; psychotherapy and drug therapy may help.
A 47-year-old man has presented to his primary care doctor eight times in the last year with concerns over a variety of minor symptoms such as dry skin, vague abdominal discomfort, and so on. He states he was in good health prior to the age of 46. At each visit, full history, examination, and appropriate lab testing reveal no physical abnormality. His doctor repeatedly reassures him of this. When the doctor does this the patient believes him, but before long he again becomes concerned about a new symptom. The symptoms themselves are less troubling to him than is the fear he feels that he might have some serious, unknown medical illness which the doctor has missed finding. On questioning, he has no other psychiatric symptoms. Though this concern about having an unknown illness is obviously genuine and very distressing to him, he never requests time off work, hospitalization, or inquires about medical disability payments.
What is the likely diagnosis?
Correct Answer C:
Hypochondriasis is characterized by a preoccupation with fears that one has a serious disease due to an unrealistic assessment of one’s symptoms. This fear persists despite reassurance, and is distressing to the patient.
A. In hypochondriasis, the fear of having a serious disease is not of delusional intensity, as seen in patients with delusional disorder, somatic type, who cannot be convinced even briefly that their beliefs are inaccurate.
B. Somatization disorder is characterized by a variety of unexplained symptoms occurring over many years and by definition must being before age 30.
D. Malingering is the intentional simulation of symptoms and/or signs of illness in order to gain some external incentive, like insurance benefits or time off work.
E. Major depressive disorder by definition includes symptoms of depressed mood or loss of interest or pleasure in life, along with a variety of other symptoms such as sleep disturbance, loss of appetite, and so on.
A woman hears of the death of her father and develops several symptoms including inability to move her arms and legs.
All of the following are associated with this conversion disorder, except:
Correct Answer D:
Conversion disorder consists of symptoms or deficits that develop unconsciously and nonvoluntarity and usually involve motor or sensory function. Manifestations resemble a neurologic or other general medical condition. Onset and maintenance of conversion symptoms are typically attributed to mental factors, such as severe stress (eg death of a loved one).
Symptoms often develop abruptly, and onset can usually be linked to a very stressful event. Symptoms are limited to those that affect voluntary motor or sensory function and suggest a neurologic or general medical condition (eg, impaired coordination or balance, weakness, or paralysis of an arm or a leg or loss of sensation in a body part).
The symptoms are severe enough to cause distress or disrupt social, occupational, or other important areas of functioning. A patient may have a single episode or sporadic repeated ones; symptoms may become chronic. Typically, episodes are brief.
La belle indifférence is considered a classic feature of conversion disorder. It is characterized by the inappropriate and paradoxical absence of distress despite the presence of an unpleasant symptom.
After a minor but distressing automobile accident, a patient is unable to move one leg. Careful physical examination demonstrates no obvious injury that might have caused the paralysis. His reflexes are intact. A CT of the spine demonstrates no back injury. The patient is reassured, and the paralysis resolves over a 2 week period.
Which of the following is the most likely diagnosis?
Correct Answer B:
This case illustrates conversion disorder. In this condition, physical symptoms are caused by psychological conflict. The symptoms develop unconsciously and are, by definition, limited to those that mimic a neurologic disorder, such as impaired coordination, weakness, paralysis, loss of sensation, blindness, deafness, or inability to speak. The onset is usually abrupt and linked to a stressful event. In most patients, symptoms improve within 2 weeks, although some patients will have persistent or recurrent problems.
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