CHAPTER 22

1. Somatoform, Factitious, and Dissociative Disorders CHAPTER 22

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

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

4. 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

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

6. 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

7. 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

8. 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

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

10. 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

11. Somatoform Disorders:Implementation • Basic level interventions • Promotion of self-care activities • Health teaching and health promotion • Case management • Pharmacological interventions • Advanced practice interventions • Psychotherapy

12. 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

13. Examples of Factitious Disorders Factitious disorder with physical symptoms Munchausen syndrome Factitious disorder with psychological symptoms Factitious disorder by proxy

14. 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)

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

16. 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

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

18. 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

19. 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

20. Dissociative Disorders: Assessment • Identity and memory • History • Moods • Impact on patient and family • Suicide risk

21. Dissociative Disorders:Implementation • Basic level interventions • Milieu therapy • Health teaching and health promotion • Pharmacological interventions • Advanced practice interventions • Cognitive-behavioral therapy • Psychodynamic psychotherapy

22. 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.

23. 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.