A. Definitions

1. Illness Behavior
   1. Verbal or nonverbal actions which communicate physical or mental distress
   2. Potential is to elicit appropriate assistance
2. Abnormal Illness Behavior (AIB)
   1. Illness behavior in excess or deficit of objectifiable disease
   2. Illness behavior in excess or deficit to elicit appropriate assistance
3. Attention Deficit Hyperactivity Disorder / Hyperkinetic Disorder
4. Paraphilia (Pedophilia)
5. Borderline Personality Disorder
6. Adolescents born prematurely (<33 weeks) have increased behavioral and neurocognitive problems, and up to 50% have abnormal MRI findings [1]
7. Functional Somatic Syndromes
8. Toxic Leukoencephalopathy can present with behavioral changes [2]
9. Increased risk for reduced cognitive scores and behavioral abnormalities in preterm infants related to gestational age at birth [3]

B. Disorders with Voluntary Symptom Production

1. Factitious Disorder
   1. Physical symptoms created by person to assume role of patient
   2. If results in hospitalizations, then called Munchausen's Syndrome
   3. Patients frequently know a fair amount of medicine (may be nurses or doctors)
   4. Early psychiatric intervention is very helpful and major form of therapy
   5. Prevent hospitalizations and avoid invasive procedures
2. Malingering
   1. Deliberate simulation of physical or psychological symptoms to achieve specific benefit
   2. Suspect if symptoms or disability greatly exceed objective disease and some secondary gain is obvious
   3. Distinguish from Factitious Disorder where only goal is to become a patient

C. Hypochondriasis [4]

1. Description
   1. Magnification of importance / severity of physical symptoms
   2. Chronic Disorder
   3. Mild: fleeting worry
   4. Severe: persistent and incapacitating dread
2. Patients typically have extensive yet unsatisfactory health care history
3. Present in ~5% of general internal medicine outpatients
   1. ~65% of patients have coexisting psychiatric disorder
   2. Major depression (40%), panic disorder (15%), obsessive compulsive disorder (8%)
   3. Generalized anxiety disorder is also more prevalent than in general population
4. Recommended Interventions [4]
   1. Cognitive-behavioral therapies (CBT) over 6 sessions is very effective [9]
   2. Psychopharmacologic treatments - mainly antidepressants
   3. Schedule frequent appointments to see patient (that is, not just for new symptoms)
   4. Diagnostic and therapeutic conservatism
   5. Validate patient's symptoms
   6. Explain patient's symptoms
   7. Aim for care rather than cure

D. Conversion Disorder

1. Definition
   1. Disorder of unexplained loss or alteration of body function
   2. Symptoms often express psychological conflict or need
   3. Symptoms often simulate neurological disease
2. Symptoms (unconsciously produced)
   1. Anmesia
   2. Aphonia
   3. Blindness
   4. Paralysis
   5. Numbness
   6. Seizures
3. Primary Gain - protection from an apparent internal conflict
4. Secondary Gain - symptoms which allow patient to avoid onerous tasks or undesirable duties
5. Diagnosis by interview with patient on lorazepam or other medication

E. Somatiform Pain Disorder [5]

1. Pain in excess / distress than is typical for a particular condition
2. Symptoms
   1. Mnemonic for symptoms = "Somatiform Disorder Befalls Ladies And Vexes Physicians"
   2. Shortness of Breath
   3. Dysmenorrhea
   4. Burning in genital area and/or rectum
   5. Lump in throat (dysphagia, odynophagia)
   6. Amnesia
   7. Vomiting (frequently occurs throughout pregnancy)
   8. Pain
3. Symptoms may be present co-temporally or separated in time
4. Treatment
   1. Diagnostic Label - recognition after careful review of medical history is essential
   2. Validate distress - do not refute symptoms
   3. Relaxation (eg. Biofeedback)
   4. Psychotherapy
   5. Treat underlying anxieties
5. Some patients with somatozation have depression, and this should be investigated

F. Attention Deficit Hyperactivity Disorder (ADHD) [6]

1. Also called "Hyperkinetic Disorder" (HKD)
2. Triad Symptom Complex (ICD-10 and DSM-IV)
   1. Inattention
   2. Hyperactivity
   3. Impulsivity
3. Treatment
   1. Methylphenidate (Ritilin®, Concerta®, others) is mainstay of therapy
   2. Tricyclic antidepressants, such as Imipramine, less effective
   3. Clonidine may have some activity in this disorder, especially for sleep and tics [7]
   4. Psychosocial intervention therapy is preferred in some parts of Europe
   5. Combination modality therapy may be beneficial
   6. Novel norepinephrine reuptake inhibitors in development
4. Prognosis
   1. In past, prognosis has been poor
   2. ADHD is a major risk factor for psychosis

G. Paraphilia (Pedophilia) [8]

1. Paraphilia is defined as deviant sexual behavior
   1. Pedophilia and exhibitionism are most common forms
   2. Pedophilia is defined as reucrrent sexual urges with fantasies surrounding children
2. Annual incidence of sexual molestation of children in USA is 100,000-500,000
3. Overall, 10-20% of children may have been sexually mollested
4. Etiology
   1. May be related to obsessive-compulsive disorder
   2. Alternatively, may be due to hypersexualism
5. Treatment
   1. Generally difficult; often unsuccessful
   2. Therefore, incarceration is often the only "sure" preventative
   3. Surgical or medical castration
   4. Medical castration usually with gonadotropin-releasing hormone (GnRH) agonists
   5. Long acting GnRH agonist triptorelin with psychotherapy may be effective therapy [8]
   6. Anti-androgens such as medroxyprogesterone or cyproterone acetate less effective
   7. Serotonergic drugs may also be useful

References

1. Stewart AL, Ribkin L, Amess PN, et al. 1999. Lancet. 353(9165):1653
2. Filley CM and Kleinschmidt-DeMasters BK. 2001. NEJM. 345(6):425
3. Bhutta AT, Cleves MA, Casey PH, et al. 2002. JAMA. 286(6)728
4. Barsky AJ. 2001. NEJM. 345(19):1395
5. Barsky AJ. 1997. JAMA. 278(8):673
6. Swanson JM, Sergeant JA, Taylor E, et al. 1998. Lancet. 351(9100):429
7. Clonidine. 1996. Med Let. 38(989):109
8. Rosler A and Witztum E. 1998. NEJM. 338(7):416
9. Barsky AJ and Ahern DK. 2004. JAMA. 291(12):1464