Somatoform Factitious and Dissociative Disorders CHAPTER 22 Elsevier

Somatoform, Factitious, and Dissociative Disorders CHAPTER 22 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 1

Somatoform Disorders • Physical symptoms suggest a physical disorder for which there is no demonstrable base • Strong presumption that symptoms linked to psychobiological factors Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 2

Somatoform Disorders • Somatization disorder • Undifferentiated somatoform disorder • Conversion disorder • Pain disorder • Hypochondriasis • Body dysmorphic disorder • Somatoform disorder not otherwise specified Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4

Hypochondriasis • Misinterpretation of physical sensations • Overconcern for health and preoccupied with symptoms • Extreme worry and fear • Course of illness chronic and relapsing Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8

Etiology • Biological factors • Genetics • Biochemical imbalances that cause pain to be experienced more intensely • Psychosocial factors – Psychoanalytic theory – Behavioral theory – Cognitive theory Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10

Somatoform Disorders: Implementation • Basic level interventions – Promotion of self-care activities – Health teaching and health promotion – Case management – Pharmacological interventions • Advanced practice interventions – Psychotherapy Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12

Examples of Factitious Disorders • Factitious disorder with physical symptoms • Munchausen syndrome • Factitious disorder with psychological symptoms • Factitious disorder by proxy Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13

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) Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14

Dissociative Disorders • Disturbances in the normally wellintegrated continuum of consciousness, memory, identity, and perception • Unconscious defense mechanism • Protects individual against overwhelming anxiety Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 15

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16

Dissociative Amnesia • Inability to recall important personal information • Often of traumatic or stressful nature – Generalized amnesia – Localized amnesia – Selective amnesia Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17

Dissociative Fugue • Sudden unexpected travel away from the customary locale • Inability to recall one’s 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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18

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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19

Dissociative Disorders: Assessment • Identity and memory • History • Moods • Impact on patient and family • Suicide risk Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20

Dissociative Disorders: Implementation • Basic level interventions – Milieu therapy – Health teaching and health promotion – Pharmacological interventions • Advanced practice interventions – Cognitive-behavioral therapy – Psychodynamic psychotherapy Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21

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. = Don’t 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. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22

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. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 23