Antidepressant medications (fluoxetine, sertraline, citalopram, and clomipramine) may be of benefit in the treatmentof unexplained headaches, fibromyalgia, BDD, somatoformpain, irritable bowel syndrome, and functional gastrointestinal disorders. Tricyclic antidepressants (clomipramineand others) should be avoided in youth with functional abdominal pain (FAP) because they have no proven efficacyin either pain management or mood disorders and are verydangerous in overdose. In chronic fatigue syndrome with comorbid depression and anxiety, a more activating antidepressant, like bupropion, can be useful. Stimulants may also be helpful in CFS.
Cognitive-behavioral methods, which reward health-promoting behaviors and discourage disability and illness behaviors, help in the treatment of recurrent pain, CFS, fibromyalgia, and FAP. Interpersonal and expressive psychotherapies in the presence of psychological trauma are particularly useful. Self-management strategies, such as self-monitoring, relaxation, hypnosis, and biofeedback, provide some symptomatic relief and encourage more active coping strategies. Family therapy and family-based interventions can be very useful. Home schooling should be avoided, and school attendance and performance should be emphasized as important indicators of appropriate functioning. In dealing with pain symptoms (e.g., headaches, stomachaches) parents should remove or limit attention for pain behavior; strongly encourage sticking to schedule (e.g., going to school); help the child identify stress at home and school; provide attention and special activities on days when child does not have symptoms; and limit activities and interactions on sick days. Discussions about excessive discomfort or illness should be replaced with having the child practice relaxation techniques and educating personnel working with their child about these approaches.
In contrast to somatoform disorders, patients intentionally simulate or create their problems in factitious disorders and malingering.
Factitious disorder is a condition in which physical orpsychological symptoms are produced intentionally but forunconscious reasons to assume a sick role. This diagnosis is made either by direct observation or by eliminatingother possible causes. Most patients are immature, passive,and hypochondriacal. They show improvement when confronted with their behavior or acknowledge the factitiousnature of their symptoms. It has been associated with borderline personality traits and substance abuse disorders.Approximate answers (e.g., 20−3=13) reported during amental status examination are most commonly found infactitious disorders.
Munchausen syndrome by proxy (MBP) is a form of factitious disorder by proxy, where a parent (usually mother) mimics symptoms in his or her child. The motivation is believed to be a psychological need to assume a sick role through the child. Of these mothers, more than 72% have a history of factitious disorder or a somatoform disorder, and up to 80% of involved parents have some health care background. MBP is a type of child abuse. Boys are more commonly abused in this way, and neonates and preschoolers are the most common victims. Both factitious disorder by proxy (diagnosis of the abuser) and pediatric condition falsification (diagnosis of the child) are needed for diagnosis.
Common presenting symptoms include vomiting, diarrhea,respiratory arrest, asthma, seizures, incoordination, fever, bleeding, failure to thrive, rash, hypoglycemia, and loss of consciousness. Simulation of psychiatric disorders is rare. Nearly 75% of the morbidity to the child occurs in hospitals from invasive procedures. Once confronted with negative test results or discharge planning, the perpetrators may become intensely enraged and acutely suicidal or may initiate legal action so the treatment team should take appropriate precautions. Mortality in MBP may be as high as 33%, and siblings of these children are also at risk. Virtually all children suffer serious psychological sequelae from this form of abuse. Treatment involves protecting the child from further abuse and reporting to child protective services.