Download Personality, Dissociative, Somatoform Dissorders

Back to Basics 2009
Somatoform Disorders
Personality Disorders
Dissociative Disorders
Dr René Ducharme
Hôpital Montfort
Somatoform Disorders
•
•
•
•
•
•
Somatisation Disorder
Conversion Disorder
Hypochondriac Disorder
Body Dysmorphic Disorder
Pain Disorder
Somatoform Disorder NOS
SOMATOFORM DISORDERS
• Somatization has been defined as the “tendency
to experience and communicate psychological and
interpersonal distress in the form of somatic
distress and medically unexplained symptoms for
which medical help is sought” (Lipowski,1988)
• Kellner conceptualizes somatization as the
“occurrence of physical symptoms that are not
supported by recognizable or sufficient physical
pathology”
1 True statements about somatoform disorders
include all of the following except
a) Patients present with somatic complaints that
suggest major medical illness but have no
associated serious and demonstrable peripheral
organ disorder
b) Psychological factors and conflict are important
in initiating and maintaining the disorders
c) Patients with these disorders are not malingerers
d) Symptoms or magnified health concerns are
under the patient’s conscious control
e) None of the above
Why is somatization important?
• If persistent, it can be associated with significant
psychological suffering, as well as occupational
and social dysfunction
• May lead to excessive health care use
• One study(Ford,1983) estimated that Somatization
accounted for about 10% of direct health care
costs
• May account for 25-50% of primary care visits
2
Conversion reactions
a) Are always transient
b) Are invariably sensorimotor as opposed to
autonomic
c) Conform to usual dermatomal distribution of
underlying peripheral nerves
d) Seem to change the psychic energy of acute
conflict into a personally meaningful metaphor
of bodily dysfunction
e) All the above
3
According to DSM, a patient with
conversion disorder would most typically
have
a) Feigned symptoms
b) Sexual dysfunction
c) La belle indifférence
d) An urban background
e) Symptom onset after age 50
4 True statements about hypochondria
include all of the following except
a)
b)
c)
d)
e)
Depression accounts for a major part of the total picture
in hypochondria
Hypochondriac symptoms can be part of dysthymia
disorders, generalized anxiety disorder or adjustment
disorder
Hypochondria is a chronic and somewhat disabling
disorder
Recent estimates are that 4 to 6 percent of the general
medical population meet the specific criteria
Significant numbers of patients with hypochondria
report traumatic sexual contacts, physical violence and
major parental upheaval before the age of 17
5
a)
b)
c)
d)
e)
Body Dysmorphic disorder is associated
with
Major depressive disorder
Obsessive compulsive disorder
Social phobia
Family history of substance abuse
All of the above
6
A patient with somatization disorder
a) Presents the initial physical complain after age
30
b) Has had physical symptoms for 3 months
c) Has complained of symptoms not explained by a
known medical condition
d) Usually experiences minimal impairment in
social or occupational functioning
e) May have a false belief of being pregnant with
objective signs of pregnancy, such as decreased
menstrual flow or amenorrhoea
Somatization disorder
epidemiology
•
•
•
•
•
Lifetime prevalence is 0.1%-0.2%
Five to twenty times more prevalent in women
Frequency inversely related to social class
Most often begins in teens, often with menarche
15% have a positive family history; higher
concordance rate in monozygotic twins
• Risk of alcohol abuse, depression and antisocial
personality disorder is increased in relatives
Particularities
• Pseudocyesis is somatoform disorder NOS
PAIN DISORDER
• According to the Diagnostic and Statistical Manual of Mental
Disorders IV (DSM-IV), somatoform disorders are characterized by
"the occurrence of one or more physical complaints for which
appropriate medical evaluation reveals no explanatory physical
pathology or pathophysiologic mechanism, or, when pathology is
present, the physical complaints or resulting impairment are grossly in
excess of what would be expected from the physical findings. »
• Pain disorder can be divided into 2 categories:
• Pain disorder associated with psychological factors and no identifiable
general medical condition: Psychological factors play a major role in
the onset, severity, exacerbation, or maintenance of the pain.
• Pain disorder associated with psychological factors and a general
medical condition: Both the psychological factors and the general
medical condition have important roles in the onset, severity,
exacerbation, or maintenance of the pain.
Pain disorder
• Symptoms vary depending on the site of pain and are treated
medically. However, there are common symptoms associated with pain
disorder regardless of the site:
• negative or distorted cognition, such as feeling helpless or hopeless
with respect to pain and its management
• inactivity, passivity, and/or disability
• increased pain requiring clinical intervention
• insomnia and fatigue
• disrupted social relationships at home, work, or school
• depression and/or anxiety
Clinical Features
• Fluctuating ,waxing and waning course
• As many as 75% have co-morbid Axis I
diagnoses
• Most common co-morbid diagnoses are
major depression, dysthymia, panic
disorder, simple phobia and substance abuse
• Personality disorders also more common
7 Among the following recommendations arising
from general therapeutic principles for somatoform
disorders, which one must be avoided
a) Foster a therapeutic relationship that
recognizes the person’s suffering
b) Plan regular appointments
c) Treat associated mood disorders
d) Identify and interpret the patient’s
unconscious motivations
e) Identify any personality disorder
General Approach to the Somatizing
Patient
•
•
•
•
•
•
Regularly scheduled appointments
Further diagnostic procedures, hospitalizations and
surgery should be avoided unless there are clear medical
indications
Medications should be kept to a minimum
Treat co-morbid mental disorders, most commonly
depressive and anxiety disorders, as well as substance
abuse disorders
Validate the patient’s experience of physical distress
without reinforcing illness preoccupation
Do not forget to consider unusual illness presentations
such as in SLE, HIV and MS to name a few
Pharmacotherapy
•
•
•
•
Very few studies done
Use Tricyclic Antidepressants for chronic pain
Identify and treat associated Axis I disorders
Treatment of Body Dysmorphic Disorder with
SSRI
• Symptoms of hypochondria shown to improve
with Fluoxetine in one small open-label study
Psychotherapy
• In general, psychoeducational and supportive
techniques predominate, although insight-oriented
therapy may be indicated in some patients
• Group therapy may be particularly useful in
enhancing interpersonal skills
• Cognitive-behavioural therapy well studied in
hypochondria and may be the treatment of choice
for many somatoform disorders
• Behaviour treatment used in Hypochondria, Body
Dysmorphic and Pain Disorder
Approach to the patient with
Conversion Disorder
•
•
•
•
Explain that conversion symptoms are not
caused by a serious illness
Refrain from confronting the patient
Provide some sort of face-saving
explanation
Frequently suggestion works ‘‘ You will
get better soon”
Factitious Disorders
• Intentional production or feigning of physical
or psychological signs or symptoms
• Motivation is to assume the sick role
• External incentives are absent
• An extreme form presenting with physical
symptoms has been termed “Munchausen’s
Syndrome” and Munchausen by proxy
Baron von Munchausen
Malingering
• Intentional production of false or grossly
exaggerated physical or psychological
symptoms, motivated by external incentives
such as avoiding military duty, avoiding
work, obtaining financial compensation,
evading criminal prosecution, or obtaining
drugs. It is a fraud, a crime.
Remember
• The process of somatization is presumed to
be unconscious
• Factitious disorders and Malingering are the
exception to this rule
• Malingering is not a mental disorder.
However it is a condition that may require
medical attention.
Personality Disorders
8 PD are characterized by enduring patterns
of behavior in four of the following five areas.
In which do they not appear
a) Self perception
b) Spiritual beliefs
c) Emotional expression
d) Relationships with others
e) Degree of impulsiness
General Diagnostic Criteria
- Personality Disorder (DSM IV-TR)
A.
An enduring pattern of inner experience and behavior that deviates markedly from
expectations of the individual’s culture… manifested in 2 or more of:
1.
Cognition (ways of perceiving and interpreting self, other people, events)
2.
Affectivity (range, intensity, lability, appropriateness of emotional response)
3.
Interpersonal functioning
4.
Impulse control
B.
Pattern is inflexible and pervasive across a broad range of personal and social
situations.
C.
Pattern causes clinically significant distress or impairment in social, occupation or
other important areas of functioning.
D.
Pattern is stable and of long duration… onset at least in adolescence or early
adulthood.
E.
Pattern is not manifestation or consequence of another mental disorder.
9
True statements about the aspects of
personality called «temperament» include all
of the following except
a) They are heritable
b) They are observable early in childhood
c) They are relatively stable in time
d) They are inconsistent in different cultures
e) They are predictive of adolescent and
adult behavior
Definitions
Personality: enduring patterns of perceiving, relating to,
and thinking about the environment and oneself.
Personality Disorder:
• Personality traits which are inflexible and maladaptive
• significant functional impairment or subjective distress
• recognizable by adolescence; continue through adult life
• ego-syntonic: not regarded as undesirable by itself
• ego-dystonic: perceived as painful, no self
Classification
• Cluster A: odd or eccentric:
• Paranoid, Schizoid, Schizotypical
• Cluster B: dramatic, emotional, impulsive:
• Antisocial, Borderline, Histrionic, Narcissistic
• Cluster C: anxious, fearful:
• Avoidant,
• Dependant,
• Obsessive-Compulsive
10 True statements about diagnosing specific
personality disorder include
a) Diagnosis may not be made in children
b) Antisocial personality disorder may be
diagnosed in individual under 18
c) There is a potential sex bias in diagnosing
PD
d) Real gender differences do not exist in the
prevalence of PD
e) All the above
11
a)
b)
c)
d)
e)
Antisocial PD is associated with an
increased risk for
Major depressive disorder
Anxiety disorder
Somatization disorder
Borderline PD
All the above
12
a)
b)
c)
d)
e)
Borderline PD is associated with
Decreased risk for psychotic symptoms
Increased risk for premature death
Decreased risk for other coexisting PD
Decreased risk for bulimia
Decreased risk for PTSD
13
a)
b)
c)
d)
e)
The etiology of borderline PD involves
Chilhood trauma
Vulnerable temperament
Emotional dysregulation
Familial aggregation
All of the above
14 Select the trait that is the most associated
with the one numbered PD
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
Schizoid
Schizotypical
Avoidant
Obsessive compulsive
Histrionic
Narcissistic
Borderline
Dependent
Paranoid
Antisocial
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
Is interpersonally exploitative
Exaggerated fears of being unable to
care for himself
Is unable to discard worthless objects
Feels attacked by other remarks
Is preoccupied with being criticized
in social situations
Is uncomfortable in situations in
which he is not the centre of attention
Relationships characterized by
alternating between extremes of
idealization and devaluation
Neither desires nor enjoys close
relationships
Odd interests and behaviors
Do not care for is own safety
15
People who are prone to dependent PD
include all of the following except
a) Men
b) Younger children
c) Persons with chronic physical illness in
childhood
d) Persons with a history of separation
anxiety disorder
e) Children of mothers with panic disorder
Defenses Mechanisms
• Cluster A : Projection, fantasy
• Cluster B : Splitting, projective
identification, denial, acting-out,
dissociation
• Cluster C : Isolation, passive-aggression,
somatization
Therapy of PD
Psychotherapy
•
The most evidence based treatment
•
Goal is rehab not cure
•
Many years but can be intermittent
•
Borderline most studied: Dialectic and CBT and Psychodynamic
•
Cluster A: Paranoid, Cluster B : Antisocial, Narcissistic: ego-syntonic, no
insight for change
•
Cluster B: Histrionic, Cluster C : CBT
Therapy of PD
•
Pharmacotherapy
•
Target symptoms, partial benefits
•
May be harmful: overdose, deceiving, side effects
•
Over time
•
Antisocial and borderline improve
•
10% rate of suicide among borderline
DISSOCIATIVE DISORDER
•
•
•
•
•
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Disorder
Dissociative Disorder NOS
Dissociative symptoms
1.
2.
3.
4.
Increase with age
Are always considered pathological
Are more common in women than men
Psychologically represent a self-defense
against trauma
5. Is a first stage of development of
psychosis
Dissociation
• Dissociation is an unconscious defence mechanism
whereby a group of mental processes is separated from the
rest of mental activities; it may include the separation of a
thought from its emotional content, as can be seen in
dissociative disorders or conversion disorders
• Dissociation is commonly seen in traumatized individuals
and is often used to “not deal” with negative emotions or to
deal in a surviving mode
16 DSM includes dissociative symptoms in
the criteria for all but which of the following
disorder?
a) Acute Stress disorder
b) Somatization disorder
c) Post Traumatic Stress disorder
d) Obsessive Compulsive disorder
e) Borderline Personality disorder
17
All of the following are true statements
about dissociative fugue except
a) It is a rare type of DD
b) It is not characterized by behavior that
appears extraordinary to others
c) It is characterized by a lack of awareness
of the loss of memory
d) It is usually a long-lasting state
e) Recovery is spontaneous and rapid
Dissociative Disorders
• Dissociative Amnesia: characterized by an
inability to recall important personal information,
usually of a traumatic or stressful nature, that is
too extensive to be explained by ordinary
forgetting
• Dissociative Fugue: characterized by a sudden,
unexpected travel away from home or one’s
customary place of work, accompanied by an
inability to recall one’s past and confusion about
personal identity or the assumption of a new
identity
18 Each of the following statements about
dissociative identity disorder is true except
a) The transition from from one personality
to another is often sudden and dramatic
b) The patient generally has amnesia for the
existence of the other personalities
c) Each personality rarely seeks treatment
d) The host personality rarely seeks
treatment
e) The personalities may be of both sexes
Dissociative Disorders
• Dissociative Identity Disorder: characterized by the
presence of two or more distinct identities or
personality states that recurrently take control of the
individual’s behaviour accompanied by an inability to
recall important personal information that is too
extensive to be explained by ordinary forgetfulness.
19
a)
b)
c)
d)
e)
Depersonalization disorder is
characterized by
Impaired reality testing
Ego-dystonic symptoms
Occurrence in the late decades of life
Gradual onset
A brief course and a good prognosis
Dissociative Disorders
• Depersonalization Disorder: characterized by a
persistent or recurring feeling of being detached from
one’s mental processes or body that is accompanied
by intact reality testing
• Dissociative Disorder NOS: the predominant
feature is a dissociative symptom, but does not meet
criteria for any specific dissociative disorder (eg EgoState Disorder; Dissociative Trance Disorder;
Possession Trance Disorder)
20 Patients predisposed to dissociative fugue
include those with all of the following except
a)
b)
c)
d)
e)
Mood disorders
Schizophrenia
Histrionic PD
Heavy alcohol abuse
Borderline PD
Answers Réponses
• 1 d, 2 d, 3 c, 4 a, 5 e, 6 c, 7 d,
• 8 b, 9 d, 10 c, 11 e, 12 b, 13 e,
• 14 1 h, 2 i, 3 e, 4 c, 5 f, 6 a, 7g, 8 b, 9 d,
10 j, 15 d,
• 16 d, 17 d, 18 d, 19 b, 20 b