Somatoform, Factitious, and Dissociative Disorders

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CHAPTER 22

• Somatoform, Factitious, and Dissociative
  Disorders

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Somatoform Disorders

• Physical symptoms suggest a physical disorder for
  which there is no demonstrable base
• Strong presumption that symptoms linked to
  psychobiological factors

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Somatoform Disorders

• Somatization disorder
• Undifferentiated somatoform disorder
• Conversion disorder
• Pain disorder
• Hypochondriasis
• Body dysmorphic disorder
• Somatoform disorder not otherwise specified

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Somatization Disorder

• Most common somatoform disorder
• Significant functional impairment
• Symptoms
• Pain, GI symptoms, sexual symptoms, and
  pseudoneurological symptoms
• Course of illness chronic and relapsing
• Suicide threats and gestures common

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Hypochondriasis

• Misinterpretation of physical sensations
• Overconcern for health and preoccupied with
  symptoms
• Extreme worry and fear
• Course of illness chronic and relapsing

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Pain Disorder

• Diagnostic testing rules out organic cause
• Discomfort leads to impairment
• Associated with higher rates of depression
• Usual sites of pain are head, face, lower back,
  pelvis

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Body Dysmorphic Disorder

• Preoccupation with an imagined defective body
  part
• Obsessional thinking and compulsive behavior
• Fear of rejection by others, perfectionism, and
  conviction of being disfigured lead to emotions
  of disgust, shame and depression

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Conversion Disorder

• Presence of deficits in voluntary motor or
  sensory functions
• Common symptoms paralysis, blindness, movement
  and gait disorders, numbness, paresthesias, loss
  of vision or hearing, or episodes resembling
  epilepsy
• La belle indifférence versus distress
• Comorbid conditions depression, anxiety, other
  somatoform disorders, personality disorders

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Etiology

• Biological factors
• Genetics
• Biochemical imbalances that cause pain to be
  experienced more intensely
• Psychosocial factors
• Psychoanalytic theory
• Behavioral theory
• Cognitive theory

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Somatoform Disorders Assessment

• Symptoms and unmet needs
• Voluntary control of symptoms
• Secondary gains
• Cognitive style
• Ability to communicate feelings and emotional
  needs
• Dependence on medication

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Somatoform DisordersImplementation

• Basic level interventions
• Promotion of self-care activities
• Health teaching and health promotion
• Case management
• Pharmacological interventions
• Advanced practice interventions
• Psychotherapy

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Factitious Disorders

• Consciously pretend to be ill to get emotional
  needs met and attain status of patient
• Three subtypes
• Predominately physical symptoms
• Predominantly psychological symptoms
• Combinations of physical and psychological
  symptoms

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Examples of Factitious Disorders

• Factitious disorder with physical symptoms
• Munchausen syndrome
• Factitious disorder with psychological symptoms
• Factitious disorder by proxy

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Malingering

• Symptoms are consciously produced or feigned
• Have various motivations, including financial
  gain, relief of work duties, or obtaining illicit
  drugs
• Obvious secondary gain(s)

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Dissociative Disorders

• Disturbances in the normally well-integrated
  continuum of consciousness, memory, identity, and
  perception
• Unconscious defense mechanism
• Protects individual against overwhelming anxiety

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Depersonalization Disorder

• Alteration in perception of self
• Reality testing remains intact
• Disturbing experiences of
• Feeling a sense of deadness of the body
• Seeing oneself from a distance
• Perceiving limbs to be larger or smaller than
  normal

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Dissociative Amnesia

• Inability to recall important personal
  information
• Often of traumatic or stressful nature
• Generalized amnesia
• Localized amnesia
• Selective amnesia

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Dissociative Fugue

• Sudden unexpected travel away from the customary
  locale
• Inability to recall ones identity and some or
  all of the past
• During fugue state tend to live simple, quiet
  lives
• When former identity remembered, become amnestic
  for time spent in fugue state

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Dissociative Identity Disorder

• Presence of two or more distinct personality
  states
• Primary personality (host) usually not aware of
  alters
• Alternate personality (alters) or
  subpersonalities take control of behavior
• Alters often aware of each other
• Each alter thinks and behaves as a separate
  individual

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Dissociative Disorders Assessment

• Identity and memory
• History
• Moods
• Impact on patient and family
• Suicide risk

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Dissociative DisordersImplementation

• Basic level interventions
• Milieu therapy
• Health teaching and health promotion
• Pharmacological interventions
• Advanced practice interventions
• Cognitive-behavioral therapy
• Psychodynamic psychotherapy

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Personal Challenges to Professional Practice

• Focus on your feelings and be cognizant of your
  reactions.
• Monitor your own feelings of defensiveness,
  impatience, frustration, or anger toward the
  client.
• Practice increased self-awareness.
• Dont judge, criticize, or make assumptions.
• Pain is determined and defined by the client.
• Pain of psychic origin is as hurtful as pain of
  biologic origin.

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Personal Challenges to Professional Practice

• Be alert for signs of secondary gain.
• Avoid reinforcing negative behaviors.
• Address client with a matter-of-fact approach.
• Reinforce adaptive vs. maladaptive behaviors.