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

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

3. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3 Somatoform Disorders Somatization disorderSomatization disorder Undifferentiated somatoform disorderUndifferentiated somatoform disorder Conversion disorderConversion disorder Pain disorderPain disorder HypochondriasisHypochondriasis Body dysmorphic disorderBody dysmorphic disorder Somatoform disorder not otherwise specifiedSomatoform disorder not otherwise specified

4. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4 Somatization Disorder Most common somatoform disorderMost common somatoform disorder Significant functional impairmentSignificant functional impairment SymptomsSymptoms –Pain, GI symptoms, sexual symptoms, and pseudoneurological symptoms Course of illness chronic and relapsingCourse of illness chronic and relapsing Suicide threats and gestures commonSuicide threats and gestures common

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

6. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6 Pain Disorder Diagnostic testing rules out organic causeDiagnostic testing rules out organic cause Discomfort leads to impairmentDiscomfort leads to impairment Associated with higher rates of depressionAssociated with higher rates of depression Usual sites of pain are head, face, lower back, pelvisUsual sites of pain are head, face, lower back, pelvis

7. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7 Body Dysmorphic Disorder Preoccupation with an imagined defective body partPreoccupation with an imagined defective body part Obsessional thinking and compulsive behaviorObsessional thinking and compulsive behavior Fear of rejection by others, perfectionism, and conviction of being disfigured lead to emotions of disgust, shame and depressionFear of rejection by others, perfectionism, and conviction of being disfigured lead to emotions of disgust, shame and depression

8. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8 Conversion Disorder Presence of deficits in voluntary motor or sensory functionsPresence 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 epilepsyCommon symptoms – paralysis, blindness, movement and gait disorders, numbness, paresthesias, loss of vision or hearing, or episodes resembling epilepsy “La belle indifférence” versus distress“La belle indifférence” versus distress Comorbid conditions – depression, anxiety, other somatoform disorders, personality disordersComorbid conditions – depression, anxiety, other somatoform disorders, personality disorders

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

10. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10 Somatoform Disorders: Assessment Symptoms and unmet needsSymptoms and unmet needs Voluntary control of symptomsVoluntary control of symptoms Secondary gainsSecondary gains Cognitive styleCognitive style Ability to communicate feelings and emotional needsAbility to communicate feelings and emotional needs Dependence on medicationDependence on medication

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

12. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12 Factitious Disorders Consciously pretend to be ill to get emotional needs met and attain status of “patient”Consciously pretend to be ill to get emotional needs met and attain status of “patient” Three subtypesThree subtypes –Predominately physical symptoms –Predominantly psychological symptoms –Combinations of physical and psychological symptoms

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

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

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

16. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16 Depersonalization Disorder Alteration in perception of selfAlteration in perception of self Reality testing remains intactReality testing remains intact Disturbing experiences ofDisturbing 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. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17 Dissociative Amnesia Inability to recall important personal informationInability to recall important personal information Often of traumatic or stressful natureOften of traumatic or stressful nature –Generalized amnesia –Localized amnesia –Selective amnesia

18. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18 Dissociative Fugue Sudden unexpected travel away from the customary localeSudden unexpected travel away from the customary locale Inability to recall one’s identity and some or all of the pastInability to recall one’s identity and some or all of the past During fugue state tend to live simple, quiet livesDuring fugue state tend to live simple, quiet lives When former identity remembered, become amnestic for time spent in fugue stateWhen former identity remembered, become amnestic for time spent in fugue state

19. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19 Dissociative Identity Disorder Presence of two or more distinct personality statesPresence of two or more distinct personality states Primary personality (host) usually not aware of altersPrimary personality (host) usually not aware of alters Alternate personality (alters) or subpersonalities take control of behaviorAlternate personality (alters) or subpersonalities take control of behavior Alters often aware of each otherAlters often aware of each other Each alter thinks and behaves as a separate individualEach alter thinks and behaves as a separate individual

20. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20 Dissociative Disorders: Assessment Identity and memoryIdentity and memory HistoryHistory MoodsMoods Impact on patient and familyImpact on patient and family Suicide riskSuicide risk

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

22. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 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. 22

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