NEUROTIC DISORDERS Somatoform, Factitious and Dissociative Disorders

1
NEUROTIC DISORDERSSomatoform, Factitious and
Dissociative Disorders

• Vudhichai Boonyanaruthee, MD
• Department of Psychiatry
• Chiang Mai University

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What is Abnormal?

• Abnormal - literally means away from the normal
  so Einstein was abnormal.
• Society Abnormal behavior must be defined within
  the context of the society.
• A practical definition Behavior is abnormal
  when it causes the individual or those around him
  discomfort, distress, or danger.

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A Brief History

• Primitive peoples - saw abnormal behavior as a
  sign that the person was possessed by demons or
  spirits
• Golden age of Greece - Hippocrates and others
  viewed mental illness as a natural phenomenon
  like other illness
• Middle ages - a return to belief in possession
  and demonology. Knowledge was kept alive in the
  Islamic countries.

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Approaches to Psychological Disorders

• diathesis-stress model A diathesis-???????
  is a genetic or other biological predisposition
  or vulnerability ??????????. Under stress, a
  person may develop a disorder to which he/she is
  predisposed.
• systems approach Biological, psychological,
  and social risk factors combine to produce
  disorders. Also known as the Biopsychosocial
  model

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Classifying Psychiatric Disorders

• Diagnostic Statistic Manual of Mental Disorders
  (4th edition) DSM IV Published by the American
  Psychiatric Association
• It is the most widely used classification system
  of psychological disorders.
• It is a listing of disorders, their symptoms, and
  statistical data (e.g., gender, age, differences)
• It does NOT specify treatments and does NOT list
  causes of disorders

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NEUROSIS V PSYCHOSIS

• OUT OF REALITY
• DISORGANIZED SPEECH
• DISORGANIZED BEHAVIOR
• THOUGHT DISORDER( FORM/CONTENT)
• IMPAIRED INSIGHT
• IMPAIRED JUDGMENT

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NEUROSIS

• INTRAPSYCHIC CONFLICTS SEX AGGRESSION,
  DEPENDENCY NEED
• DEFENSE MECHANISM

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NEUROSIS

• ANXIETY NEUROSIS
• PHOBIC NEUROSIS
• OBSESSIVE-COMPULSIVE NEUROSIS
• HYSTERICAL NEUROSIS CONVERSION TYPE,
  DISSOCIATIVE TYPE
• DEPRESSIVE NEUROSIS
• SEXUAL DISORDERS
• etc.

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NEUROSES V DSM - IV

• ANXIETY NEUROSIS V GENERALIZED ANXIETY DISORDER
• PHOBIC NEUROSIS V PHOBIC DISORDER
• OBSESSIVE-COMPULSIVE NEUROSIS V OCD
• HYSTERICAL NEUROSIS V CONVERSION DISORDER,
• DISSOCIATIVE DISORDER
• DEPRESSIVE NEUROSIS V DYSTHYMIC DISORDER
• etc.

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NEUROTIC DISORDERS

• ANXIETY DISORDERS
• SOMATOFORM DISORDERS
• DISSOCIATIVE DISORDERS
• SEXUAL DISORDERS

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Somatoform Disorders

• When Inner Conflict(???????????????) Leads to the
  Unconscious production of
• Physical Symptoms for Primary Gain(???????????????
  ??)

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Primary vs. Secondary Gain

• Primary Gain
• Keeping the anxiety associated with internal
  conflict out of awareness or consciousness(???????
  ??????????????????????????)
• Secondary Gain
• Tangible benefits(????????????????) from being
  sick, such as sympathy(??????????) and
  support(???????????????) from family, being
  excused(??????) from life/job obligations, and
  financial rewards(??????????????????)

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Somatoform Disorders

• Somatization Disorder
• Conversion Disorder
• Pain Disorder
• Hypochondriasis
• Body Dysmorphic Disorder
• Somatoform Disorder, Not Otherwise Specified

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What is Somatization?

• Experiencing physical distress/symptoms in
  response to mental/emotional conflict
• Seeking medical attention for that physical
  distress

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Historical Considerations

• Somatization formerly known as Hysteria,
  resulting from a displaced uterus (wandering
  uterus)
• Briquet- name associated with early descriptions
  of Hysteria in the 1800s

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Somatization Disorder DSM-IV Criteria

• Seeking treatment for many physical complaints,
  with onset before age 30
• Four pain symptoms
• Two gastrointestinal symptoms
• One sexual symptom
• One pseudoneurological symptom
• The symptoms are NOT intentionally produced

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Somatization Disorder Associated Features

• Stories are often vague (?????????),
  inconsistent(??????????), colorful and dramatic
  (??????? ??????????)
• Frequently seek care from multiple providers with
  repeated work-ups
• High comorbidity (??????????????) with
  personality disorders (especially histrionic)
• More common in women
• Chronic and fluctuating course (??????????????????
  ????????? ??? ??????????????)

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Conversion Disorder DSM-IV Criteria

• One or more symptoms affecting voluntary motor or
  sensory function
• Resembles neurological or medical disease
• Psychological factors must be involved
• The symptoms are NOT intentionally produced

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Examples of Conversion Symptoms

• Motor
• Paralysis
• Difficulty swallowing (dysphagia)
• Difficulty walking (ataxia)
• Tremor
• Inability to talk (aphonia)
• Seizures (Pseudoseizures)

• Sensory
• Double vision (diplopia)
• Blindness
• Deafness
• Numbness

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Where does the concept of Conversion come from?

• Freudian term
• Patients noted to convert (???????????)
  psychic conflict into bodily symptoms as a
  defense mechanism
• Commonly association with trauma

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Conversion Disorder Associated Features

• Conversion symptoms frequently seen on medical
  and surgical floors
• Symptoms often do not conform to anatomic
  pathways
• La belle indifference apparent lack of concern
  about major impairment (rare)

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Conversion Disorder Culture, Age, and
Gender Features

• More common in rural populations
• More common in individuals of lower socioeconomic
  status
• More frequent in women (femalemale ratios range
  from 21 to 101)

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Pain Disorder DSM-IV Criteria

• One or more sites of pain as primary focus
• Pain causes significant impairment
• Psychological factors are felt to have an
  important role in the pain
• The symptom is NOT intentionally produced

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Hypochondriasis
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Hypochondriasis DSM-IV Criteria

• Preoccupation (?????????? ?????) with fears of
  having a serious disease based on
  misinterpretation of bodily sensations (
  ?????????????????????????)
• Preoccupation goes on despite medical evaluation
  and reassurance (poor insight)
• Duration is at least six months

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Hypochondriasis Associated Features

• Serious childhood illnesses and past experience
  with illness in a family member are common
• Doctor-shopping and costly medical work-ups are
  common
• Appears equally common in men and women

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Body Dysmorphic Disorder DSM-IV Criteria

• Preoccupation with an imagined defect in
  appearance (?????????? ????? ?????????????????????
  ??????????????????????????????)
• If the individual already has a mild physical
  flaw (??????????) the concern surrounding it is
  excessive (???????????)

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Body Dysmorphic Disorder Associated Features

• Frequent inspection of the defect can consume
  many hours a day, lead to suicidal thoughts
  (????????????????????????????)
• Insight is often poor- can become
  delusional(??????????)
• Medical and surgical treatments are often pursued
• High prevalence in cosmetic surgery
  (??????????????) and dermatology clinics
  (????????????????)

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Factitious Disorder

• I know Im producing my symptoms, but I dont
  understand why

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Factitious Disorder DSM-IV
Criteria

• Intentional production of physical or
  psychological signs and symptoms
• The motivation (?????????) for the behavior is to
  assume the sick role (??????????????????)
  (primary gain)
• External incentives (??????????????) (such as
  economic gain, or avoiding responsibilities) are
  absent (i.e., no secondary gain)

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Examples of methods to produce Factitious symptoms
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Examples of methods to produce Factitious
symptoms( in 41 patients)

• _________________________________________________
• Method
• _________________________________________________
• ??? ???????????????????????????????????????
  29
• ?????????????????????????? 24
• ?????????? 17
• ??????????????????????? 10
• ??????????????????????? 7
• ????????????????????????? 7
• ??????????????????????????? 2
• ??????????????? 2
• _________________________________________________
• Sourse. Adapted from ReichP, Gottfried LA
  Factitious disorders in a teaching hospital.
• Ann Intern Med 99 240-247, 1983.

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Factitious Disorder Associated Features

• Often involves multiple hospitalizations at
  multiple sites
• Invasive procedures and surgery
• Usually have few visitors while in the hospital
• Patients often have extensive knowledge of
  medical terminology (health care workers, etc.)

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Munchausen Syndrome?

• Another term for Factitious Disorder
• Baron Von Munchausen was a fictional
  eighteenth-century character known for
  story-telling, exaggeration and frequent travel

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Munchausen by Proxy

• Parent induces illness in a child
• The child is repeatedly hospitalized as a result

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Malingering

• Im faking it, I know it,
• and Im getting something out of it

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Malingering

• Intentional production of false or exaggerated
  physical or psychological symptoms
• The malingerer is aware that he is producing the
  symptoms for gain (secondary gain)

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In Summary
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Dissociative Disorders

• Multiple Personality, and more

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Dissociative Disorders

• Dissociative Amnesia
• Dissociative Fugue
• Dissociative Identity Disorder
• Depersonalization Disorder
• Dissociative Disorder, Not Otherwise Specified

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Dissociative Amnesia DSM-IV Criteria

• One or more episodes of inability to recall
  (????????) important personal information
• Information is usually related to a traumatic or
  stressful event
• Cant be explained by simple forgetfulness

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Dissociative Amnesia Associated Features

• Appears to be a common short-term reaction in
  both men and women to severe stress
• Three-fourths of cases resolve over several days
  (self-limited)

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Dissociative Fugue DSM-IV
Characterization

• Sudden, unexpected travel away from home with an
  inability to remember the past (retrograde
  amnesia)
• Confusion ????????? about personal identity
  (?????????) or assumption of new identity
• Commonly associated with trauma

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Dissociative Identity Disorder DSM-IV Criteria

• Formerly called Multiple Personality Disorder
• The presence of two or more distinct identities
  or personality states
• At least two of these personalities regularly
  take control of a persons identity
• Inability to recall important personal
  information (cant be explained by forgetfulness)

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Dissociative Identity Disorder Associated
Features

• Usually a primary identity carries the persons
  given name
• Alternate personalities tend to have different
  names and contrasting personalities
• Transitions among identities is often caused by
  stress
• Frequently a history of severe physical and/or
  sexual abuse(????????????????????) during
  childhood

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Dissociative Identity Disorder Gender and
Prevalence

• Overall rare, (less than 1 prevalence), however,
  diagnosed three to nine times more frequently in
  adult females
• Rise in diagnosed cases in recent years
• Due to greater awareness ?
• Overdiagnosed in suggestible individuals?

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Depersonalization Disorder

• Feeling detached (???)from and outside of ones
  body (like youre in a dream)
• During the experience reality testing is still
  intact (not a psychotic episode)
• Prevalence is unknown, but appears common in mild
  form
• Many people without psychiatric pathology have
  had this experience

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Derealization

• A feeling or experience that the external world
  is strange or unreal
• May occur during Depersonalization Disorder
• Other people may seem unfamiliar or mechanical
• Size or shape of objects in external world may
  seem altered

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Recommendations for Treatment of Dissociative
Disorders

• Rule out medical causes
• Medications not helpful with Dissociation, but
  may help with comorbid anxiety or depression
• Depersonalization Disorder may respond to SSRIs
• Therapy is most helpful