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Factitious disorder
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Illness anxiety disorder
Malingering
Somatic symptom disorder
Upper airway cough syndrome
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This patient presents with an excessive fear of having an illness (lung cancer) despite having minimal symptoms and a normal physical examination, which is indicative of illness anxiety disorder. Illness anxiety disorder, formerly called hypochondriasis, is characterized by excessive concern about having a serious medical illness despite minimal somatic symptoms and a normal physical examination. Illness anxiety exists along a spectrum, from normal to pathologic. Illness anxiety is considered pathologic when the patient’s anxiety causes significant distress or functional impairment. Patients with illness anxiety disorder frequently have comorbid generalized anxiety disorder, major depression, and specific phobias. The differential diagnosis should include somatic symptom disorder, in which patients have more significant somatic symptoms (e.g., abdominal pain). In contrast, patients with illness anxiety disorder are more preoccupied with their belief that they have a serious medical illness. The treatment of illness anxiety disorder is to improve patient coping skills by scheduling regular primary care visits and attempting to establish a therapeutic alliance. In patients with persistent symptoms, cognitive behavioral therapy is indicated. Reuman et al. studied the predictors of illness anxiety symptoms in patients with obsessive compulsive disorder. The authors found that illness anxiety symptoms were associated with obsessions with harm and compulsive checking behavior in these patients. They recommended that clinicians be familiar with the common obsessions and compulsions that are associated with illness anxiety symptoms in order to better care for patients with this disorder in the primary care setting. Incorrect Answers: Answer 1: Factitious disorder is characterized by patients feigning illness to assume the sick role in the absence of external gain (e.g., financial gain, avoiding work). The key difference between illness anxiety disorder and factitious disorder is that patients with factitious disorder may feign symptoms but do not actually believe that they are ill whereas patients with illness anxiety disorder harbor beliefs that they are seriously ill. This patient believes that she has a serious medical illness, making illness anxiety disorder more likely. Answer 3: Malingering is a form of factitious disorder where patients feign illness for some external gain. This external gain usually takes the form of financial gain, avoidance of work, or avoidance of repercussions for criminal behavior. As with factitious disorder, patients who are malingering do not actually believe that they are ill. Answer 4: Somatic symptom disorder is characterized by the presence of 1 or more somatic symptoms such as vague abdominal pain that causes significant distress or impairment. Patients with this disorder frequently have a history of an invasive diagnostic work-up that is negative. In contrast to patients with illness anxiety disorder who have minimal symptoms, somatic symptoms are featured prominently in patients with somatic symptom disorder. Answer 5: Upper airway cough syndrome is caused by nasal secretions passing into the nasopharynx and upper airway, triggering a chronic cough. Physical examination would show nasal erythema and inflammation. This patient has an extremely mild cough and a normal physical examination, and her excessive worry about having lung cancer makes illness anxiety disorder more likely. Bullet Summary: Illness anxiety disorder is characterized by an excessive fear of having a serious medical illness despite having minimal somatic symptoms.
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