Download Distress Disorder and Psychosomatic Disorders Dr James Rodger

Producing a Formulation, Differentiating between
Distress and Disorder, Psychosomatic Disorders
Dr. James Rodger
Consultant Child & Adolescent
Psychiatrist, South Devon CAMHS
Overview
• Differentiating distress from disorder – what
the manuals tell us
• Beyond impairment – models of disorder
• Validity of mental disorder
• Formulation
• Somatisation
Differentiating between Distress
and Disorder
“Correct answer”?
• DSM-IV-TR
– polythetic symptom criteria
– episode fit (is there a better fit?) / developmental
criteria / duration criteria
– causing clinically significant distress or
impairment (educational, occupational, social,
family life)
– D: diagnostic fit (superordinate diagnosis, organic
causes excluded?)
Case example - ADHD
• The DSM criteria - two groups:
– Inattentive (9) and hyperactive-impulsive (6+3)
symptoms (inconsistent with developmental level)
• Six of the nine symptoms in each section must be present
for a ‘combined type’ diagnosis of ADHD.
• if insufficient symptoms for a full diagnosis
– predominantly inattentive (ADHD-I)
– predominantly hyperactive (ADHD-H)
• Supported by factor-analysis studies
– most studies supporting a two-factor model of
symptom “clustering” (as above)
DSM-IV-TR
– symptoms must be chronic (> 6 months) and
present before age 7
– symptoms present in 2 or more settings but
evidence of significant impairment required
in only one setting (social, school or work)
– not occuring exclusively in context of PDD or
psychosis, not better accounted for by another
disorder (e.g. Anxiety, ?RAD)
ICD-10 hyperkinetic disorders
• Almost identical symptom list but need symtom
count in all 3 domains accross >2 contexts:
– 6/9 inattentive
– 3/5 hyperactive
– 1/4 impulsive
• Significant distress or impairment 1 or more contexts
• More rigourous exclusion (psychosis, PDD, mood,
anxiety)
• Prevalence rates much lower (<50%) using ICD
Prevalence - UK
• British Child and Adolescent Mental Health Survey
1999 (n>10,000)
– parents / teachers + impairment (clinical process)
– 3.62% of boys and 0.85% of girls had ADHD
– 4.25:1 M:F.
• more restricted diagnosis ICD10-hyperkinetic 
prevalence = 1.5% for boys (primary school)
Natural Rates of ADHD!
• UK prevalence estimate up to 16% (Taylor 1991)
• In USA prevalence estimates 8-25%
• Worldwide high variability (DSM-IV)
– Low: Australia 2.4 – 10% (DSM-IV
– High: Brazil, Colombia, Germany, Ukraine 15-20%
• majority of variability  methods used
–
–
–
–
Criteria
Rating scales vs. more in depth interview
Impairment
Sources of information (single / multiple)
• minor differences worldwide (NICE) ~ 5.3%
Impairment
• Fundamental to diagnostic validity (as ADHD
symptoms on spectrum with normal population)
• Without criterion of impairment  2x  prev
• Newcastle (McArdle et al., 2004).
–
–
–
–
11% if no impairment
6.7% moderately low impairment
4.2% for moderate impairment
1.4% for severe pervasive impairment
Is distress and/or impairment
enough?
• Being gay can be very distressing, if you, or your
family, or wider society don’t want you to be – but
we don’t call homosexuality a…. err… burn the
previous editions
• Roland Littlewood a psychiatrist and anthropologist
describe a woman in her 30s, who by our standard
would have met all several criteria for schizophrenia,
but was not distressed, and formed a new religious
movement “Mother Earth” with many followers therefore no dsyfunction?
Biomedical Definitions
• “biological disadvantage” (Scadding 1967)
– that it must at least encompass reduced fertility and life
expectancy (Kendell (1975)
• Are we happy for this to be our primary evaluative
criterion for thinking about the value of human life?
– Life style choices, homosexuality, and life within religious
orders, may all be patholgised by such a definition!
• Illogical consequences when applied to thinking
about mental disorder
– Many milder conditions such as phobias as well as
disorders with onset after the prime reproductive years
would fail to qualify as disorders and may not affect lifeexpectancy either
– Conduct disorder may confer evolutionary advantage!
Biomedical Disadvantage
= Failure of Evolutionary Design?
• dysfunction - failure of a biological mechanism
to perform a natural function for which it had
been designed by evolution (Wakefield 1992)
– Too little known about the evolution of most
of the higher cerebral functions
• Mood states such as anxiety and depression
may have evolved as biologically adaptive
responses to danger or loss
• Paranoia ,hearing voices & OCD, may have
conferred evolutionary advantage, during EEA
(Pleistocene: 1.8million – 12,000 years ago)
• Some cognitive abilities, like reading, have been
acquired too recently to be plausibly regarded as
natural functions designed by evolution
Can dysfunction be defined without reference
to evolution or disadvantage?
• “too little is known about the cerebral mechanisms
underlying basic psychological functions, such as
perception, abstract reasoning, and memory, for it to
be possible in most cases to do more than infer the
probable presence of a biological dysfunction”??
– i.e. need a frame of reference to say whether “pathology”
• “Furthermore, rejecting both the evolutionary and
biological disadvantage criteria may open the way to
regarding a wide range of purely social disabilities
(such as aggressive, uncooperative behaviour or an
inability to resist lighting fires or stealing) as mental
disorders”.
– Is this already happening?
Sociopolitical Definitions
• “disease is simply what doctors treat”!
• Although rarely advocated by physicians - treatability
is often a crucial consideration underlying their
decisions to regard individual phenomena as
diseases
• despite the advocacy of Thomas Trotter and
Benjamin Rush at the beginning of the nineteenth
century and a sustained campaign by Alcoholics
Anonymous in the 1930s, the medical profession
firmly resisted the proposal that alcoholism should be
regarded as a disease until disulfiram (Antabuse)
was introduced in the late 1940s
• As for Ritalin and ADHD >late 1960s?
Sociopolitical Definitions
• “Condition is regarded as a disease if it is agreed to
be undesirable (an explicit value judgment) and if it
seems on balance that physicians (or health
professionals in general) and their technologies are
more likely to be able to deal with it effectively than
are any of the potential alternatives, such as the
criminal justice system (treating it as crime), the
church (treating it as a sin), or social work (treating it
as a social problem)”.
• essentially pragmatic or utilitarian.
• given condition might be a mental disorder in one
setting but not in another - depending on the relative
efficacy of medical and other approaches to the
problem in those different settings…
Sociopolitical Definitions
• whether restless, overactive children with short
attention spans are regarded as having
attention-deficit/hyperactivity disorder or simply
as being difficult children would depend on
whether child psychiatrists were better at
ameliorating the problem than parents and
teachers
Combined biomedical and sociopolitical
definition
• concept of mental disorder necessarily involves both a
scientific or biomedical criterion (dysfunction) and an
explicit value judgment or sociopolitical criterion “harm”
(Wakefield 1992/99) or “handicap” (WHO)
– meets the main requirement of both the sociopolitical and the
biomedical camps
– seems to reflect the often intuitive ways in which physicians
make disease attributions for physical disease
– value judgements may vary accross cultures, and would be
important even if concrete biological substrates discovered
• Nailing down assured biological dysfunction, may still be
elusive, and definition may slide towards purely
sociopolitical definitions, masked by pseudo-science?
– ODD...CD.... .....(ADHD?)
– Also c.f. Neurodiversity Movement
ADHD as a case example:
controversies
• ‘‘ADHD is total, 100 percent fraud’’ Fred
Baughman - Pediatric neurologist (2006)
• ‘‘ADHD is real, a real disorder, a real problem,
often a real obstacle’’ Russell Barkley, leading
ADHD researcher (1995)
• “you ask me, any kid who would rather go
outside and play, than to sit in school all day
sounds pretty normal to me” (Yahoo
Questions 2008).
The place of values
Who is it a problem for?
• cultural differences in the level of activity and
inattention that is regarded as a problem
(Sonuga-Barke et al., 1993)
• teachers and parents tolerance and ability to
cope may determine whether the hyperactivity
is presented as a problem
• Children with hyperactivity rarely ask for help
themselves
Male – Female
• Clinic referred – 10:1
• Community referred – 3:1
• Disruptive behaviour drives referrals?
An “androgenist” critique
• Quantified Observation
– ethological observation and activity monitoring
confirmed that teachers more likely to attribute
symptoms of ADHD to boys than girls after
correction for actual behaviour differences (Brewis
et al. 2003)
– Mothers and female teachers statistically more
likely to initiate process of diagnosis and treament
for ADHD, than fathers / male teachers who may
view behaviour as more normative
Case Study: homosexuality
• Sexual Orientation Disorder (DSM-II revision
1974) / Ego-dsytonic homosexuality (DSM-III
1980) – located the problem within the
psychologies of gay people, rather than within
the society who stigmatised and
discriminated against them
• DSM-IV (1994) ego dystonic homosexuality
dropped, but included "sexual disorder not
otherwise specified" which could include
"persistent and marked distress about one’s
sexual orientation."
Challenges to this definition:
• Therapeutic challenges
– Recovering subjugated narratives of strength
– Explicating social causes of suffering (poverty,
discrimination etc.)
• Diagnostic challenges
– Relational Disorders in DSM-V but limited scope (e.g.
domestic violence, post-partum depression)
• Political challenges
– Neurodiversity
– Critical Psychiatry
Ostensive Definition
• Impossible, even in principle, to provide a
“semantic” or “operational” definition of the
global concept of mental illness or disorder, only
of individual illnesses or disorders” (Lilienfeld
and Marino 1995)
• The only criterion available is whether putative
or candidate disorders are sufficiently similar to
the prototypes of mental disorder (e.g.
schizophrenia and major depressive disorder)
• The best definition – remains a circular one!?
Levels of Explanation
• Even physical disease cannot be defined by one
overaching definition
–
–
–
–
–
Clinical syndrome: migraine and torticollis
Morbid anatomy: mitral stenosis
Histopathology: tumours
Chromosomal architecture: Down syndrome
Molecular structures: thalasemmias
• what is the most useful level of explanation
(utility!) yielding the most useful information for
action for a given presentation
– May be reciprocally influenced by treatment available.
Current treatments for torticollis don’t demand a
molecular level understanding, even if this was
available
Why are different levels of
explanation required?
• more a particular presentation looks similar to
others but responds differently - the more
complex the level of explanation needs to be?
• Most psychiatric disorder still defined by clinical
syndrome – current drug treatments don’t justify
a more complex biological description
• But they do justify a more complex psycho-social
/ systemic description e.g. diffential explanations
for symptoms of hyperactivity and inattention
What do we mean by validity?
• “valid” – validus = strong
– defined as “well founded” and applicable; sound and
to the point; against which no objection can fairly be
brought”
– Logic: validity is the characteristic of an inference that
must be true if all its premises are true.
• there is no single, agreed upon meaning of
validity in science, although it is generally
accepted that the concept addresses “the nature
of reality”
– its definition is an “epistemological and philosophical
problem, not simply a question of measurement”
• diagnostic vs. nosological validity
Establishing Validity: Feigner Criteria
• Robins & Guze (1970) / Feighner (1972)
– Clinical description
– Labaratory Studies (i.e. to show biological dysfunction –
includes cognitive profile?)
– Delimitation from other disorders (c.f. zone of rarity –
Kendell 2003)
– Follow-up studies (diagnostic stability & response to Rx
and outcome)
– Family studies
Diagnostic Validity
(According to NICE)
• Do Symptoms of inattention, hyperactivity
“cluster together”
• Can they be distinguished from normal
variation in the population?
• Are they distinguishable from other disorders
• Are symptoms asociated with significant
clinical and psychosocial impairments?
• Are there characteristic outcomes?
• Is there consistent evidence of genetic,
environmental or neurobiological risk
factors?
– Risks overlap / confluent with risks in normal
population depending on method used
Different Validators = Different Answers
• a hierarchy of validators must first be chosen for
a given nosologic question
– involves a value judgment and cannot be directly
addressed by empirical inquiries
– “What is the core feature of schizophrenia—that it has
a poor outcome, its Sx or that it runs in families?”
– This is not a scientific question.
• only once nosological question is set, can task of
formulating maximally valid diagnostic criteria
even begin to occur
– Could compare different diagnostic criteria for utility,
in different contexts
– DSM-V may rate relative validity of different diagnosis
but based on what?
Validity vs. Utility
(Kendell & Jablensky 2003)
• Few psychiatric diagnosis can claim nosological
validity, according to Feighner criteria (especially
hard for laboratory studies & delineation from other
disorders)
• Moving to validity for specific questions, or contextbased, moves away from notion of universal “truth”
to notion of “utility”
• Psychiatric diagnosis cannot claim to be valid, but
can claim to be useful – in certain contexts
The Case for Dimensional Classification
• Most disorders lack a “zone of rarity”
• Genetic and environmental risk cut accross diagnoses, as do
symptoms, and treatments (e.g. depression – anxiety –
somatisation / psychotic – bipolar)
• Would circumvent need for multiple diagnoses, of unclear
validity or utility (treat all?)
• Clinicians less pressured to make Procrustean decisions forcing diverse presentations into “best fit” categories
– Less information is lost
– Particularly helpful for trans-cultural work, where diagnostic
categories perceived even more problematic
• Emerging ideas in pharmacotherapy, suggest medication may
target symptoms, not syndromes – response easily measured
• Reduction of stigma, through normalisation with general
population, and lack of labelling
ADHD – validity according to
Feighner criteria
• Clinical description – symptom clusters
• Impairment – culture-context specific?
• Laboratory Studies
– Neuroimaging studies (structural & functional) not drug
naive (even if unmedicated at time of imaging)
– Functional imaging also tautologous!
– Distinguishes from other conditions, including effects of
maltreatment?
• Not well delimited from other disorders, e.g.
paediatric bipolar, emerging emotional unstable
personality disorder (impulsive subtype) and RAD
ADHD – validity according to
Feighner criteria
• Does high heritability cannot distinguish
environment from genetic influence?
– Twin studies wrongly assume equal environment (DZ vs
MZ)?
– Adoption studies methodologically weak – often
unblinded, lack adoptee control group (confounds
attachment problems), and do not account for preadoption / pre-natal experience
– Individual genes weak effect, non-specific - “how to inherit
multiple genes of small effect”
– DRD4-7 repeat (one of the highest RR 1.45) also linked
with attachment disorganisation, but only in presence of
unresolved maternal loss / trauma
• Follow-up – highly variable, depending on other
contextual factors
OUTCOMES
• persistence of symtpoms / impairment
– better prognosis if problem is inattention alone
• poor school achievement
– 32% fail to complete high school
• higher rate of disruptive behaviour disorders
• lack of friends / peer problems
– lack of constructive leisure activities
OUTCOMES
•
•
•
•
•
unemployment (67% vs. 40% controls)
antisocial / personality dysfunction
substance misuse
criminality (juvenille and adulthood)
road traffic violations and RTAs
– POOR OUTCOMES MEDIATED / MAGNIFIED BY
DEVELOPMENT OF CONDUCT PROBLEMS
• seperate but correlated factors in factor analysis  seperate
dimensions / traits of the disorder
Adult ADHD
• Recognition of persistence into adult life
– 15% of those diagnoses still meet full criteria by age 25 
prevalence 0.6-1.2% (childhood 4-8%)
– 65% persistence of some Sx (DSM “partial remission”)
• criteria may be biased towards younger
developmental stages
• Inattention may  and attention span usually will
usually  with age
– lag behind that of unaffected people and that necessary /
expected for attainment.
Adult ADHD
• Evolution of Sx
– in pre-school child: incessant and demanding
extremes of activity
– during school years child may make excess
movements during situations where calm is expected
rather than on every occasion
– in adolescence hyperactivity may present as excessive
fidgetiness rather than whole body movement;
– in adult life it may be a sustained inner sense of
restlessness.
Establishing Validity: Feigner Criteria
• Robins & Guze (1970) / Feighner (1972)
– Clinical description
– Labaratory Studies (i.e. to show biological dysfunction –
includes cognitive profile?)
• Largely non-specific
– Delimitation from other disorders (c.f. zone of rarity –
Kendell 2003)
• Few disorders truly seperate
– Follow-up studies (diagnostic stability & response to Rx
and outcome)
• Highly variable for many disorders
– Family studies
• Disorders overlap
Producing a Formulation
“A key advantage of formulation over
diagnosis is that it can be used to predict
how an individual might respond in certain
situations and to various psychotherapies
[or other interventions]”
Standard textbook approach
•
•
•
•
•
•
Socio-demographic summary
Presentation
Diagnoses / differentials
Presumed aetiologies
Management plan
Predicted response
– implicitly linked to accuracy of formulation
DSM-IV Multi-axial evaluation
•
•
•
•
I: Clinical disorders
II: Personality disorders / learning disability
III: General medical conditions
IV: Psychosocial and environmental problems,
inc:
– problems related to “primary support group”
– Educational problems
– Problems with housing / economic / social
environment
• V: Global assessment of functioning score
ICD-10: Multi-axial diagnostic formulation
• I: clinical disorders (mental and general
medical conditions) – include personality &
developmental dimensions
• II: disabilities (in personal care, occupational
functioning, functioning with family, and
broader social functioning / social roles);
• III: contextual factors (interpersonal and other
psychosocial and environmental problems);
• IV: quality of life (primarily reflecting patient's
self-perceptions, including spiritual –
culturally informed).
DSM-V Cultural Formulation
• “What problems or concerns bring you to the clinic?” & “what
troubles you the most about your problem?”
• How would you describe to others [not doctors]? Is there a
particular term / “cultural label”?
• “Why do you think this is happening to you? What do you
think are the particular causes of your”
• “What have your family, friends, and other people in your life
done that may have made your [PROBLEM] better/worse?”
• “ Is there anything about your background, e.g. your culture,
race, ethnicity, religion or geographical origin that is causing
problems/ helping in your current life situation?”
– REFLECTING ON CULTURAL IDENTITY AS SOURCE OF STRENGTH OR
OTHERWISE
DSM-V Cultural Formulation
• Clarify self-coping for the problem & listen for mental health
treatment, medical care, support groups, folk healing,
religious or spiritual counseling, or other alternative healing.
• Barriers to help-seeking, access to care, and problems
engaging in previous treatment.
– “Is there anything about my own background that might make it
difficult for me to understand or help you with your [PROBLEM]?”
• Establish goals and treatment preferences
SIRSE framework
(from Child Psychiatry, 2nd Ed Goodman and Scott)
• Symptoms
– Emotional
– Conduct
– Developmental (include: attention-activity levels-impulsivity,
speech/language, play, motor, toilet training, learning – literacy /
numeracy)
– Social relatedness: peers, family, authority, strangers
• Impact (how much distress or impairment does it cause?)
• Risks
– Bio-psycho-social
– Predisposing / precipitating / perpetuating / protective factors
• Strengths
– What assets are there to work with?
• Explanatory model
An additional framework
Rutter, Taylor & Hersov –CAAP, Modern Approaches
• Does the child have a psychiatric disorder?
• If there is a disorder does the clinical picture fit that of a recognized
clinical syndrome?
• What are the various roots of that disorder in terms of intrapsychic,
family, sociocultural and biological factors; and what are the
relative strengths of each of these root causes in this particular
patient?
• What forces are maintaining the problem?
• What forces are facilitating the child’s normal development?
• What are the strengths and competencies of the child and of the
family
• Untreated what is the likely outcome of the child’s disorder(s)?
– Is intervention necessary in this case?
• What types of intervention are most likely to be effective?
Should formulation include impact
of diagnosis itself?
• Theoretically we can hold multiple levels of explanation
in mind simultaneously
– in practice it can be difficult not to privilege one level (hard for
professionals, even harder for families?)
– different levels may have contradictory implications for action
• Whether intended or not, classification reifies disorder as a
fixed, and real entitiy, located within the individual
– a problem in psychiatry because psychiatric illness, may be more
responsive to changes in meaning and social context, than physical
illness
• Impact of diagnosis, and contingent social stigma on
self-identity (which may already be less developed and
robust)
Case: KB
• 8 yr old – presenting “Sx ADHD / ODD”
• Mum victim of CSA
• CP chronology reveals pervasive Hx of neglect,
emotional and physical maltreatment and
exposure to DV
– Impact on children minimised by mother
• Significant Speech & Language difficulties
– Receptive (ToM) and expressive (internalised dialogue)
• Would meet DSM-IV criteria for ADHD
– Would this be hlepful to give?
Formulation
• A hook to hang it all on!
• A cook-book / symptom checklist approach to
diagnosis may lead to multiple medications (c.f. Louis
Theroux in America!) and have catastophic
consequences
– e.g. Labelling a child who is victim of CSA with ADHD
Case HW
• 14 yr m
• Voice hearing (“command” violence –
self/other) – involved relationship with voices
– Triggered by hearing G/F tell him of physical abuse
– Some prior drug use
– Sees himself as “black sheep” – family withdrawal
longstanding (prognostic / Rx significance)
– Peers – streetwise, but non-confiding
• Voices reminiscent of protracted bullying –
evolves into protector – “rules of living”
– Cf. Steiner “psychic retreats”
Psychotherapeutic Formulation
• Psychodynamic
• Attachment
• Systemic (include cultural)
Systemic Formulation
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•
•
•
•
Cybernetics – homeostasis / feedback
Structural – hierarchies / boundaries
Transitions / family life cycle
Functional – what cause is the Sx serving?
Beliefs and communication – difference and
how this is understood and communicated
• Narrative – how the problem is talked about is
part of the problem
3 column systemic formulation
(Carr 2006)
Contexts
Belief systems
Family of origin issues
Beliefs about change
Social – educational –
professional networks
Acknowledged and hidden
strengths (“subjugated
narratives” – Foucault)
Constitutional factors
- Can include medical
Disorder, deficit, disability
– reframing, externalising
Behavioural patterns
Attachment: From Behaviour to Representation
Attachment classification SST
/ AAI
Strange Situation Test (SST)
Adult Attachment Interview
(AAI)
Secure /
Autonomous
Cries briefly on separation,
Coherent and relevant,
happy on reunion, secure base appropriate examples, able to
from which to explore
acknowledge episodes of
distress without overwhelmed
Anxious-ambivalent /
preoccupied - enmeshed
Distraught on separation,
clingy-inconsolable on
reunion, cannot explore
Anxious-avoidant / dismissing
Indifferent on separation and overly brief, keen to move
reunion, focused on inanimate onto next question, poverty of
object-play
description, idealisation
without evidence to back up.
Disorganised /
unresolved
Freezing, oscillation approach- Hard to follow narrative,
avoidance, anamolous
jumping from past to present,
or speaking about past “as if”
Bound up in feeling, stories
and relationships from the
past, winding, overlapping
stories, without clear
resolution
Hypothesized Parenting Styles
• Secure: attuned, able to think about child’s needs separate
from their own, flexible but able to set boundaries
• Dismissing: harsh, unreflecting, parenting style, parents
unable to attend to child’s emotional needs (or their own),
child learns to “not feel”
• Preoccupied: parent may be intermittently available but
inconsistently so – child learns to amplify distress to get their
needs met
• Unresolved: frightened or frightening parent – may be linked
to parental unresolved grief or maltreatment
Family (& cultural) scripts
• Characteristic modes of relating and
communicating distress that run in families
– Risk taking
– Dramatic – histrionic
– Medicalising / somatising
• Cultural “idioms of distress” and CBS
– Overdosing (Western – shunned in “traditional soc”)
– Somatisation
– Spirit possession / sorcery / “psychotic behaviour”
• Symptoms as attachment strategies
– eliciting care
Psychosomatic Disorders
Formulations of somatic Sx
• Family / cultural script
– may also be universal characteristic of moodanxiety states, selected or de-selected from
awareness by culturally influenced cognitive
processes (automatic somatic-scanning)
• Children less enculturated – therefore somatic
complaints more common
– May include cultural understandings of “what
doctors want to hear”
• Somatisation disorder / Sx much more commonly
reported and Dx by physician interviewer
• Children, less educated / illiterate persons, or those
with LD may have more naïve notions of medicine
Conscious or unconscious?
• Conscious
– Fictitious (or “malingering” (sic))
– Induced (by child or parent, or “for” parent)
• Unconscious
– Dissociative conversion (Freud – “hysteria”)
• Intrapsychic conflict (aggressive / sexual impulses)
• Symbolic resolution (unable to walk – fear of own
aggression? Blindness – a refusal of desire?)
• Naïve notions of neurology (children, uneducated, LD)
• Conforming to perceived expectation of parent /
doctor!
“Unconscious” (cont..)
• Traumatic dissociation (Janet)
– Flashbacks, intrusion of visual memory
– Pain, intrusion of somatic memory
– Emotional numbness, emotions “split off” in
dissociated self
– Sensory loss, ongoing pain or memory off “split
off” in dissociated self
• Functional (systemic hypothesis)
– Symptom serving a function within wider family
system: e.g. to unite parents, derail conflict
• Attachment / scripts / conscious - unconscious
Case: KK
•
•
•
•
•
17 yr F
CAMHS 15 – depression / anxiety
Hx domestic violence exposure +?
“Hit and run” RTA  PTSD  Litigation
Enmeshed relationship with mother: codependent (separation anxiety driven by?)
• Ongoing Sx – PTSD & physical pains
• Ambivalent engagement
– Attachment script / pattern – secondary gain –
fear of change?
Disorders of somatisation relevant
to childhood / adolesence
•
•
•
•
•
Somatisation disorder (roots in adolescence)
Undifferentiated somatoform disorder
Hypochondriasis
Body dysmorphic disorder
Conversion disorder (but dissociation
?normative in younger children)