01a somatoform & dissociative dis

Ciencias de la Salud

Behavioral SciencesBehavioral Sciences

Juan Héctor M. Meléndez-Romero. MDJuan Héctor M. Meléndez-Romero. MD

Behavioral SciencesBehavioral Sciences

Somatoform & Dissociative Somatoform & Dissociative DisordersDisorders

Kaplan & sadock`s (Ninth EditionKaplan & sadock`s (Ninth Edition) Chapter 17 Page 643-660Chapter 17 Page 643-660

Somatoform DisordersSomatoform Disorders Broad group of illnesses that have bodily

signs and symptoms.

Soma = body

Encopass mind-body interactions


Somatoform DisordersSomatoform Disorders

Modified from Kaplan & sadock`s (Ninth EditionModified from Kaplan & sadock`s (Ninth Edition) Chapter 17 Page 643-660Chapter 17 Page 643-660

DSM-IV-TR recognizes five specific disorders:1. Somatization Disorder Physical complaints

2. Conversion Neurological complaints

3. Hypochondriasis “Patient beliefs”

4. Body dismorphic Sx. “Body is defective”

5. Pain Symptoms of pain

Undeterminated

Not otherwise specified

Somatoform DisordersSomatoform Disorders1. Somatization

Characterized by many somaticsymptoms

The symptoms can not be explained on basis of the physical and laboratory examinations.



Kaplan & sadock`s (Ninth EditionKaplan & sadock`s (Ninth Edition) Chapter 17 43-660Chapter 17 Page 643-660

1. Somatization

Recognized by Pain, Gastrointestinal, Sexual and pseudoneurological symptoms.

Differs of other somotoform disorders because of the multiplicity of the complaints and the multiple organs symptoms.



1. Somatization synonimous

Hysteria

Briquet’s syndrome

Somatization Disorder



1. Somatization

Lifetime prevalence:women 0.2 to 2.0

%men 0.2

%

Begins before 30-year-old

Inversely related with social status



1. Somatization

Coexist with other mental disorders.

2/3 patients has mental disorders:avoidantparanoidself defeatingobssesive – compulsive

symptoms



1. Somatization etiology:

Psychosocial Factors:

avoid obligationsexpress emotionssymbolized a feeling or belief

Biological Factors:Attention and cognitive

impairmentsCytokines theory: IL, TNF, IF.



1. Somatization Disorder Diagnosis:

A. History of many physical complaints before age 30 years over a period of several years results in impairment of social and occupational functioning.

B. Individual symptoms:1) Four pain symptoms (sites)2) Two gastrointestinal symptoms3) One sexual symptom4) One pseudoneurological symptom

C. Either 1) and 2):1) Each symptom cannot be fully explained

2) In case of medical condition, there are excessive impairment that would be explained.

D. The symptoms are not intentionally produced.



1. Differential Diagnosis:

A. Multiple sclerosisB. Myasthenia gravisC. Systemic lupus erythematosusD. AIDSE. HyperparathyroidismF. HyperthyroidismG. Chronic Systemic Infections



1. Somatization Treatment:

Primary Care:

Regularly scheduled visits Listen to the somatic complaints and emotional

expressions

Psychiatry evaluation:

Individual or group psychotherapyMedication: AINEs and Placebo ?



2. Conversion

Disturbance of bodily functioning

Occurrs in a setting of stress

Produces considerable dysfunction



2. Conversion Disorder Definition:

Conversion disorder is characterized by the presence of one or more neurological symptoms that cannot be explain by a known neurological or medical disorder



2. Commmon symptoms :

Motor symptoms: Sensory deficits:

Involuntary movements AnesthesiaTics BlindnessBlepharospasm Tunnel visionTorticolis DeafnessSeizures Aphonia Visceral symptoms:Paralysis Psychogenic vomitingWeakness Pseudocyesis

Urinary retentionDiarrhea



2. Conversion Disorder Comorbidity:

Depressive disorder

Anxiety disorder

Somatization disorder

Schizopherina



2. Conversion Disorder Etiology:

Psychoanalytic factors : conversion of anxiety into a medical symptom.

Learning theory: conditioned learning behavior.

Biological factors: impaired hemispheric communication.

Tema XXTema XX

• Concepto XX


Somatoform DisordersSomatoform Disorders2. Conversion Disorder Diagnosis:

A. One or more symptoms or deficitis affecting voluntary motor or sensory function.

B. Psychological factors are jugded to be associated with the symptoms or deficit because iniciation or exacerbation of symptoms is preceded by conflicts or other stressors.

C. Symptoms are not intentionally produces.D. Symptoms cannot be explained by a general medical

condition.E. The symptoms causes clinically significant distress or

impairment of social, occupational functioning.F. The symtoms are no limited to pain or sexual dysfuntion.

Somatoform DisordersSomatoform Disorders2. Conversion Disorder Treatment:

Psychological therapy: Insight-oriented supportive or behavior therapy.

Hypnosis

Behavioral relaxation therapy

Medical Treatment: Anxiolytic drugs

Somatoform DisordersSomatoform Disorders3. Hypochondriasis

Defined as a person’s preoccupation with the fear of contracting, or belief of heaving a serious disease.

The person misinterpreat bodily symptoms or functions.

Somatoform DisordersSomatoform Disorders3. Hypochondriasis

Etiology.

Low tolerance of, low threshold for physical discomfort

Understandable in terms of a social learning model

Variant of depressive or anxiety disorder.

Somatoform DisordersSomatoform Disorders3. Diagnosis of Hypochondriasis

A. Preoccupation with fear of having, or the idea that one has a serious disease.

B. Preoccupation persist despite appropiated medical evaluation and reassurance.

C. The belief in Criterion A is not of delusional intensity.

D. The preocupation causes clinical distress or impariment of social or functioning areas.

E. Duration at least six months.F. The preoccupation is not better accounted for by

generalized anxiety disorder, separation anxiety,etc.

Somatoform DisordersSomatoform Disorders3. Treatment of Hypochondriasis

Stress reduction

Medical education in chronic illness

Treatment of depressive or mental disorder.

Somatoform DisordersSomatoform Disorders4. Body dhysmophic

Patient’s have a pervasive subjective feeling of Patient’s have a pervasive subjective feeling of ugliness of some aspecto of their appearance ugliness of some aspecto of their appearance despite a normal or nearly normal appearance.despite a normal or nearly normal appearance.

The person’s strong belief or fear that he or she The person’s strong belief or fear that he or she is unattractive or even repulsive.is unattractive or even repulsive.

Somatoform DisordersSomatoform Disorders4. Body dhysmophic

Location of Imagined Defects:Location of Imagined Defects:

HairHair LipsLips NoseNose ChinChin SkinSkin EarsEars EyesEyes PennisPennis Head or faceHead or face ButtocksButtocks Body buildBody build Breast, etc.Breast, etc.

Somatoform DisordersSomatoform Disorders4. Diagnostic Criteria for Body dhysmophic

A.A. Preoccupation with an imagined defect in Preoccupation with an imagined defect in appearance.appearance.

B.B. The preoccupation causes clinically significant The preoccupation causes clinically significant distress or impairment of social or functioning.distress or impairment of social or functioning.

C.C. The preoccupation is not betteraccounted for by The preoccupation is not betteraccounted for by another mental disorder.another mental disorder.

Somatoform DisordersSomatoform Disorders4. Diagnostic Criteria for Body dhysmophic

Relation to plastic surgeryRelation to plastic surgery

Medical treatment: Medical treatment: TryciclicsTryciclicsSSRIsSSRIsIMAO.IMAO.

Somatoform DisordersSomatoform Disorders5. Pain disorder

Presence of pain that is “the focus of clinical Presence of pain that is “the focus of clinical attention”.attention”.

Pain is not fully accounted for by a medical or Pain is not fully accounted for by a medical or neurological condition.neurological condition.

Synonimous: Synonimous: Somatoform pain disorderSomatoform pain disorderPsychogenic painPsychogenic painAtypical pain disorderAtypical pain disorderIdiopathic pain disorderIdiopathic pain disorder

Somatoform DisordersSomatoform Disorders5. Etiology of Pain disorder

Psychodynamic factors.Psychodynamic factors. Intrapsychic conflic: unable to express their feelingsIntrapsychic conflic: unable to express their feelings Displacing the problems to the bodyDisplacing the problems to the body Convinced that they have to sufferConvinced that they have to suffer

Behavioral factors.Behavioral factors.

Interpersonal factors.Interpersonal factors. Means of manipulation.Means of manipulation.

Biological factors.Biological factors. Endorphin deficiency.Endorphin deficiency.

Somatoform DisordersSomatoform Disorders5. Diagnostic Criteria for Pain disorder

A.A. Pain in one or more anatomical sites is the Pain in one or more anatomical sites is the predominant focus in clinical presentation.predominant focus in clinical presentation.

B.B. Pain causes significat distress or clinical Pain causes significat distress or clinical impairment.impairment.

C.C. Psychological factors are jugde to have an Psychological factors are jugde to have an important role in onset, severity, exacerbation and important role in onset, severity, exacerbation and maintenance of pain.maintenance of pain.

D.D. The symptom is not intentionally produced or The symptom is not intentionally produced or feigned.feigned.

E.E. The pain is not better accounted for by a mood, The pain is not better accounted for by a mood, anxiety or psychotic disorder.anxiety or psychotic disorder.

Somatoform DisordersSomatoform Disorders5. Diagnostic Criteria for Pain disorder

Medical Treatment:Medical Treatment: TryciclicsTryciclics SSRI’sSSRI’s

PsychoterapyPsychoterapy

BiofeedbackBiofeedback

Pain Control Programs.Pain Control Programs.

Dissociative DisordersDissociative Disorders

Dissociative DisordersDissociative Disorders

CharacteristicsCharacteristics

• Contradictory representation of the self.

• Produces conflicts with each other.

• They feel that they have not identity

• Can develops sevral identities

Classification Classification

There are four different types:

1. Dissociative amnesia

2. Dissociative Fugue

3. Dissociative Identity dissorder

4. Depersonalization dissorderNot otherwise specified

1. Dissociative amnesia1. Dissociative amnesia

• Amnesia is the Key symptom in this type

• Reffers to the inability to recall information, usually about stressful o traumatic events.

• Affects the recall of general information

1. Dissociative amnesia1. Dissociative amnesia

• Appears in war time or natural disasters.

• Also is related with domestic settings and emergency situations.

• Most patients can not retrive stressful memories.

• DSM-IV diagnostic criteria

2. Dissociative Fugue2. Dissociative Fugue

• The behavior of the patient with dissociative fugue is unusual and dramatic.

• Fugue = The patient travel away his from their customary home and work situations.

• Fails to remember personal data.

2. Dissociative Fugue2. Dissociative Fugue

• Its rare.

• Associated to alcohol abuse

• Desire to withdraw from emotionally painful experiences


3. Dissociative Identity disorder3. Dissociative Identity disorder

• Sinonimous: Multiple personality disorder

• Chronic disease

• Associated to traumatic events:– Child abuse– Child physical trauma

• There are two or more personalities


• In 1800 Benjamin Rush building earlier clinical report of this problem

• Freud relates with psychodynamic mechanism

• Bleuler relates with schizophrenia.

• The cause is unknown


Signs of multiplicity:

Time distorsion Change in name

Change behavior Use word “we”

Do not recognize personal objetcsAuditive hallucinations

4. Depersonalization disorder4. Depersonalization disorder

• Depersonalization disorder symptoms

• Persistent or recurrent alteration in the perseption of the self.

• His personality is temporally lost.

4. Deprsonalization disorder4. Deprsonalization disorder

• Causes: Neurological disorders

Toxic - metabolic Disorders

Mental dissease


• Course & Prognosis

01a somatoform & dissociative dis

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