somatic and dissociative disorders

somatic symptom disorder

• preoccupation w/ perceived health prob w/ no medical condition

• typical age of onset is before 30

• long list of physical complaints

• demand unnecssary tests; don’t comply with recommendations

• have significant distress

• exaggerated description of s/s

• comorbid psychiatric illness - anxiety, depression; exhibit these thru physical s.s

• often refuse psychiatric help - don’t see connection

• NOT primary gain - to return back to natural, healthy state

• secondary gains - extra benefits or attention from being sick; motivation to stay sick

• not faking s/s

illness anxiety disorder (AKA hypochondriasis)

• Extreme concern & preoccupation with having a devastating disease

• Extreme worry and fear (not under control of the patient)

• Course of illness chronic and relapsing

• No symptoms; life-threatening conditions

functional neurological disorder - conversion disorder

• deficits in voluntary motor or sensory functions (not under voluntary control)

• Common symptoms: paralysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, or episodes resembling epilepsy (no medical basis as to why it occurred; happens suddenly)

• “La belle indifférence” versus distress - they are not concerned about the symptoms

• Comorbid conditions – depression, anxiety, personality disorders, high levels of stress

genetic and familial fx for somatic disorders

• may play role in predisposition

• lower pain threshold, difficulty expressing emotions

• hx of childhood trauma/abuse

• issues w staying focused

somatic disorder assessment

• Symptoms and unmet needs (exaggerating? Vague? ADL’s?)

• Voluntary control of symptoms

• Secondary gains - Ask questions about if they are getting any attention due to their condition. 

• Cognitive style - How are they interpreting the stimuli (could be misinterpreting them)

• Ability to communicate feelings and emotional needs - How do they describe their needs and emotions?

• Dependence on medication

basic intervnetions for somatic disorder

• Promotion of self-care activities - Tell/explain to them what they need them to do (shower, brush teeth, get dressed, etc.)

• Health teaching and health promotion - Educate them on their symptoms and how they can be normal (help w/ stimuli)

• Case management

• Pharmacological interventions - SSRI’s (most effective), antidepressants, antianxiety

advanced interventions for somatic disorder

psychotherapy

factitious disorder

• Deliberately fabricate symptoms of illness or self-injury without obvious gains

• Want to assume the “sick role”

• Conscious effort/choice; no symptoms

• Factitious disorder imposed on self (Munchausen Syndrome) - Does things to make themselves sick (ingest poison, mess w/ labs)

• Factitious disorder imposed on another (Munchausen by proxy) - Usually on children who aren’t able to defend themselves. 

malingering

consciously feigning an illness for benefits (gain disability, out of prison and to mental hospital, insurance fraud)

dissociative disorders

• disturbances in norm well-integrated continuum of consciousness, memory, identity, and perception

• unconscious defense mechanism

• protect person against overwhelming anxiety

• reality-testing is intact

• alterted mind-body connection

dissociative disorder types

• depersonalization/derealization disorder

• dissociative amnesia with fugue

• dissociative amnesia

• dissociative identity disorder

depersonalization/derealization disorder

• Recurrent episodes of feeling unreal, detached, outside of one’s own body, numb, or in a dreamlike state

• Experiencing a distorted sense of time or visual perception

• Reality testing remains intact

• It is as if they are looking outside of their body at themselves

dissociative amnesia

• Inability to recall important personal information (goes beyond normal forgetfulness; includes memory gaps)

• Often of traumatic or stressful nature

• Generalized amnesia - The inability to recall information for a larger time gap; like childhood period

• Localized amnesia - The inability to recall information around a specific event or time period; shorter period

dissociative amnesia w fugue

• Sudden unexpected travel away from the customary locale 

• Inability to recall one’s identity and some or all of the past

dissociative identity disorder

• Often referred to Multiple Personality Disorder

• Presence of two or more distinct personality states (alters)

• Primary personality (host) usually not aware of alters

• Alternate personality (alters) or sub-personalities take control of behavior (especially when in high anxiety situations)

• Alters often aware of each other

• Each alter thinks and behaves as a separate individual

dissociative disorder assessment

• Rule out medical cause (are they talking in 3rd person? Could be their altered state)

• Identity and memory (do they black out)

• History - Seizure disorders, head trauma?

• Moods (screen for depression, anxiety, etc.)

• Impact on patient and family

• Suicide risk

basic interventions for dissociative disorders

• Milieu therapy (calm, quiet environment)

• Health teaching and health promotion - Teach about healthy coping skills, stress management 

• Pharmacological interventions - Antianxiety, SSRIs (no specific medication intended for this)

advanced interventions for dissociative disorders

• cognitive-behavioral therapy

• psychodynamic psychotherapy