Somatoform, dissociative and factitious disorders

1. Somatoform, dissociative and factitious disorders Dr. Anil Kakunje Professor of Psychiatry, YMC

2. Overview • Somatoform disorder • Dissociative disorder • Hypochondriasis • Factitious disorder

3. What will you learn ? • Identification of psychosomatic illness • Differentiating between them • Management approaches

4. Basic definitions • Somatoform disorders (Somatic symptom disorders) • Soma- body • pathological concern of individuals with the appearance or functioning of their bodies when there is no identifiable medical condition causing the physical complaints

5. Somatoform Disorders • Somatoform Disorders • Multiple physical complaints of various systems • Usually starts at young age before the age of 30 yrs

7. Somatoform Disorders • Somatization disorder • Briquet’s syndrome • patients have a history of many physical • complaints that can not be explained by a medical condition, the complaints are not intentionally produced • Persistent refusal to accept the advice of several doctors- doctor shopping • 20% of patients in primary care • develops during adolescence – • Treatment – pharmacotherapy and reassurance, cognitive-behavioral therapy (CBT)

8. Hypochondriacal disorder - Persistent preoccupation with the possibility of having one or more serious diseases…..HIV…TB…TUMOUR Normal sensations and appearances are often misinterpreted by a patient.

10. DISSOCIATIVE DISORDER • Dissociative disorders • Individuals feel detached from themselves or their surroundings, and reality, experience, and identity may disintegrate • Precipitated by stress

11. Historically, both somatoform and dissociative disorders used to be categorized as hysterical neurosis • -in psychoanalytic theory neurotic disorders result from underlying unconscious conflicts, anxiety that resulted from those conflicts and ego defense mechanisms

12. Dissociative (conversion) Disorders • Partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. • Previously classified as ‘conversion hysteria’. • They are ‘psychogenic’ in origin- associated closely in time with traumatic events, insoluble problems/disturbed relationships.

13. Dissociative (conversion) Disorders • Dissociative amnesia: Amnesia is usually centred on traumatic events, such as accidents or unexpected bereavements. Eg: Soldiers forgetting some events during battle. • Dissociative fugue: amnesia plus an apparently purposeful journey away from home or place of work during which self care is maintained. Occasionally new identity is assumed. • Dissociative stupor: profound diminution or absence of voluntary movement and normal responsiveness- Motionless for long time.

14. Dissociative (conversion) Disorders • Trance and possession disorders: • individual acts as if taken over by another personality, spirit, deity or ‘force’, repeated set of movements, postures and utterances; occur outside culturally accepted situations. • Dissociative disorders of movement and sensation:loss of or interference with movements or loss of sensations; the disability helps the patient to escape from an unpleasant conflict, or to express dependency or resentment indirectly;

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17. FACTITIOUS DISORDERS • Factitious disorders • a person acts as if they have an illness by deliberately producing, feigning, or exaggeratingsymptoms. • NOT MALINGERING 

19. Factitious Disorders • Munchhausen’s syndrome/hospital hopper syndrome: • Individual feigns symptoms repeatedly and consistently. • Self-infliction of cuts or abrasions to produce bleeding, • The imitation may be so convincing- repeated investigations and operations are performed at several different hospitals. • The motivation is obscure- disorder of illness behaviour/sick role. • DD: Malingering- intentional production of symptoms , motivated by external incentives like evading criminal prosecution, obtain sickness benefits etc.

21. Conversion vs somatoform vs factitious vs malingering

22. Take home message • Dissociative, somatoform and factitious disorders present with vague somatic symptoms, often to the physicians. • Unnecessary and expensive investigations to be avoided. • Empathic approach helps. • Referral to psychiatrist/ consultation liaison with psychiatrist is important in managing these problems.

23. THANK YOU