Dr.Aws khasawna. SomatoformDisorders+Distortion disorders+learning disorders. Dana Entabi. 1 P a g e

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1 1 P a g e #4 SomatoformDisorders+Distortion disorders+learning disorders Dr.Aws khasawna Dana Entabi

2 Greetings, Somatoform Disorders At the beginning, Soma= Body. It's the diseases which include the somatizations, which is one of the defense mechanisims. Somatization: It's important to differentiate between somatization previously and presently: Previously: They thought that when any body have to be diagnosed with somatization he must to be medically free. Presently: An exepression of psychological pain through physical symptoms or concerns. Unexplained physical symptoms or badly preoccupations. 2 P a g e

3 Types of somatization: 1) Somatization disorder, conversion disorder, pain disorder, undifferentiated somatoform disorder: Experiencing pain or physical symptoms with no apparent medical basis. 2) Hypochondriasis: Preoccupation with having a serious medical condition or disease. 3) Body Dysmorphic Disorder: Preoccupation with a perceived serious defect in appearance. Characteristics of the Somatoform Disorders: A) Psychological factors are associated with the initiation or exacerbation of symptoms. B) Diagnoses of exclusion diagnosis requires you to rule out: 1) Underlying general medical causes. 2) Other psychological disorders, Ex. an Anxiety or Mood Disorder. 3) Intentional feigning or production of symptoms, as in: Factitious Disorder : Motivated by a desire to assume the sick role. Malingering : Motivated by external incentives for behavior, Ex. economic gain, avoiding legal responsibility. 3 P a g e

4 (A) Somatization Disorder: Diagnostic Criteria, (History of physical symptoms): - beginning before age of 30 - occurring over several years Must include: 1)Four different pains They don't appear at the same time, they begin in 25 year until 30. 2)Two gastrointestinal symptoms (Nausea, diarrhea..ect) 3)One sexual/reproductive symptom 4)One pseudo-neurological symptom Resulting in treatment being sought or significant impairment in functioning Facts & Figures: 1)Prevalence: 0.2-2% among women; less than 0.2% among men. 2)Course: Chronic, fluctuating disorder, rarely remits completely. 3)Onset: Adolescence, before 25 years old. 4 P a g e

5 4)Most common among those who are: (a) Unmarried (b) Female. (c) lower education (d) from lower SES groups. (e)family history of depression. (f) substance abuse. (g) antisocial personality disorder Treatment Considerations: 1)Long term supportive psychotherapy: Therapist can provide an important, reassuring, sympathetic relationship; use brief, widely-spaced sessions. 2)Antidepressants : Comorbid condition or anxiety 3)Use of a gate-keeper physician: A patient with somatization disorder usually don't go to psychiatric doctor at the begining, instead he tend to go to (family doctor, internist and these doctors will take the managing step ( gate keeper), the doctor usually will do his best to manage the case, after a good patient-doctor relationship the doctor now can send the patient to the psychiatric 5 P a g e 4)Work in tandem with a primary care physician & psychiatrist.

6 (B) Conversion Disorder: (hysteria) Facts & Figures: (A) More common in: 1) Rural populations 2) Lower social economic status. 3) Less medically/psychologically sophisticated 4) Women than men (2-10x): Previously they believe that this disease affect the women only, by immigration of the uterus, with neurological defect on the place that the uterus stay on, (if it on the nose : she cannot smell, on the hand: she will have hand (B) In women, symptoms are much more common on the left than right side of the body. (C) out of 100,000 in general population meet criteria for conversion disorder (D) 3% of outpatient referrals to mental health clinics (E) 1-14% of medical/surgical inpatients (F) Onset: late childhood through early adulthood; rarely before 10 or after P a g e

7 Diagnostic Criteria: (A) One or more symptoms or deficits affecting voluntary motor or sensory functioning and indicative of a neurological or other medical condition. (B) Psychological factors are associated with the symptoms the initiation or exacerbation of Symptoms is preceded by conflicts or stressors. (C) The Symptoms is not intentionally feigned or produced, as in Factitious Disorder or Malingering (D) The Symptoms cannot be fully explained by a general medical condition, the effects of a substance, or a culturally sanctioned behavior or experience. (E) Symptoms cause significant distress or impairment in functioning or warrant medical attention (F) The Symptoms is not limited to pain or sexual dysfunction, does not occur exclusively in the course of Somatization Disorder, and is not better accounted for by another mental disorder. Theory: (A) Psychoanalytic: 1) The person experiences a traumatic event, which produces anxiety and psychological conflict 2) Anxiety and unconscious psychological conflict are converted to somatic symptoms 3) Symptoms provide primary gain: Which mean we have a psychological conflict converted to neurological defect, so in this disorder we have only a neurological somatoform disorder which will affect the nervous system( motor or sensory) by this reduce anxiety and keep the conflict out of awareness. 7 P a g e

8 4)Symptoms provide secondary gain: How the society will deal with this patient: (The person obtains external benefits, such as attention or sympathy, or evades noxious duties and responsibilities) (B) Getting sick provides the person an escape from a traumatic situation : Previously They believe that these deficit in those patients is symbolic presentation of trauma. Like if he saw any unfavorable thing, he became blind. (C) Hx of significant stress (D) Over-involved and over-protective parents (E) Prior experience with real physical problems: Ex. 19 years young female presented with urinary retention, History: She exposed to unfavorable thing (trauma), her father has a prostate problems ( Family history of urinary retention), with nothing showed in the investigation (Normal bladder).so she has prior experience with real physical problem with her father, and this is occur unconsciously. (F) Underlying psychopathology: (Psychiatric co-morbidity). 8 P a g e

9 Treatment Considerations: (A) Role of suggestibility patients can be suggested into & out of Symptoms. (B) Identify and attend to the traumatic or stressful life event. (C) Address current psychosocial stressors with environmental manipulation, support, advice, and coping skills (D) Reduce any reinforcing or supportive consequences from the conversion symptoms. (E) For acute Symptoms: Positive expectation for recovery, a face-saving way for the patient to recover, Ex. physical therapy (F) For chronic Symptoms: Physical rehabilitation, suggestion & psychotherapy. (G) Work closely with a medical doctor and psychiatrist. 9 P a g e

10 (C) Pain disorder: Diagnostic Criteria: (A) Pain in one or more anatomical sites is the predominant focus of clinical presentation and is of sufficient severity to warrant clinical attention. (B) Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. (C) Pain causes clinically significant distress or impairment in important areas or functioning or warrants medical attention. (D) Pain is not intentionally feigned or produced, as in Factitious Disorder or Malingering. (E) Pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder. Types of Pain Disorder: Pain Disorder Associated with Psychological Factors Psychological factors have a major role in the: Onset, Severity, Exacerbation, or maintenance of pain. Pain Disorder Associated with a General Medical Condition GMC or site of pain is coded on Axis III: Low back, sciatic, pelvic, headache, chest, joint, abdominal, throat, urinary Pain Disorder Associated with Both Psychological Factors and a General Medical Condition Most common 10 P a g e

11 Specifiers: (A) Acute: duration less than 6 months. (B) Chronic: duration 6 months or longer. Treatment Considerations: (A) Pain management: Teach techniques for coping with pain; use of analgesic, antiinflammatory, and antidepressant medications. Analgesic use only with pain associated with medical condition, it has nothing to do with psychological one. (B)Cognitive behavioral techniques: Distraction, stress management, cognitive restructuring, activity pacing, sleep management, logging activities attempted and level of pain associated with each, meditation and biofeedback Logging activities: Putting a schedule for daily activity, and let the paitent to write the degree of the pain he feel it every time he do each one of them. The purpose of this: even if the pain still there but by this they can coexist with pain. 11 P a g e

12 (D)Hypochondriasis: (illness anxiety disorder) The name derived from: Previously they thought that the cause of this disorder is problem in the organs beneath the sternum cartilage. Diagnostic Criteria: 1) Preoccupation with fear of having or belief that one has a serious illness, based on misinterpretation of bodily symptoms or functions. 2) Preoccupation persists despite appropriate medical evaluation, reassurance, and the person s not developing the feared disease 3) Preoccupation lasts at least 6 months. 4) Preoccupation causes clinically significant distress or impairment in important areas of functioning. 5) Preoccupation is not better accounted for by other disorders, such as generalized anxiety disorder, obsessive compulsive disorder, Panic Disorder, Major Depression, Separation Anxiety, or another Somatoform Disorder. Causes : (A) Faulty interpretation of bodily cues and sensations as evidence of physical illness (B) Enhanced sensitivity to, & over-focusing on, physical sensations and illness cues 12 P a g e

13 (C) Stressful life events (D)Disproportionate incidence of disease in family during childhood (E)Secondary gains associated with the sick role: decreased responsibility and increased attention Treatments: (A) Cognitive behavioral treatment: identifying & challenging illnessrelated misinterpretations of bodily sensations; showing patients how to create symptoms by focusing attention on certain body areas. (B) Stress management. (C) Explanatory therapy: reassurance & education regarding the source and origins of symptoms. (E) Body Dysmorphic Disorder: (BDD) Diagnostic Considerations: (A) Preoccupation with an imagined defect in appearance or markedly excessive concern about a slight physical anomaly. (B) The preoccupation causes clinically significant distress or impairment in important areas or functioning. (C) The preoccupation is not better accounted for by another mental disorder, such as distorted body image in Anorexia Nervosa 13 P a g e

14 Usually these paitents don t go to psychiatric clinic, instead they tend to go to dermatology and plastic surgery. Mostly these paitents will make problems after the therapy, they became dissatisfied of there appearance, because actually they don t have any defect in there appearance before that. Common Features: (A) Constant and excessive use of mirrors. (B) Avoidance of mirrors. (C) Lots of time spent grooming. (D) Lots of grooming rituals. (E) Attempts to hide parts of body. (F) Constantly seeking reassurance about looks, while discounting feedback. (G )Anxiety or depression about one s appearance. Facts & Figures: (A) People with BDD often seek help from dermatologists and plastic surgeons (rates of BDD in these settings is 6-15%) (B) BDD is under-recognized & under-diagnosed in nonpsychiatric settings (C) BDD is infrequent in mental health settings (D) Onset: adolescence and young adulthood. 14 P a g e

15 Causes : (A) Defense mechanism of displacement: displacing underlying psychological conflict and anxiety onto a body part. (B) Variant of OCD. (C) Culturally-influenced, but not culture-bound: How can the society influence the BDD? Ex. Once upon a time there was a young lady who had a small problem. She didn t like her nose What might be the influence of shows like The Swan (Fox), Extreme Makeover (ABC), I Want a Famous Face (MTV). Treatment : (A) Pharmacotherapy: SSRI s at higher doses & for longer duration. (B) CBT (Cognitive behavioral therapy) strategies: Exposure and response prevention, self-esteem building, modifying distorted thinking, and coping strategies. With all previous disorders we must exclude Malingering and Factitious Disorder 15 P a g e

16 Malingering: It's a behavior NOT a disorder. The intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives. Examples of the incentives: 1)Avoiding work. 2)Obtaining financial compensation. 3)Avoiding military duty. 4)Evading criminal prosecution. 5)Obtaining drugs. Malingering vs. Factitious Disorder Malingering The motivation for symptom production is an external incentive Factitious Disorder The external incentive is absent. there is a need to maintain the sick role. This is also known as Munchausen s syndrome: Sever form of FD. 16 P a g e

17 Dissociative Disorders The category of dissociative disorders includes a wide variety of syndromes whose common core is an alteration in consciousness that affects memory and identity. (A) Dissociative Amnesia. (C) Dissociative Identity Disorder. (B) Dissociative Fugue. (D) Depersonalization Disorder. (A) Dissociative Amnesia: Symptoms Etiology Treatment Loss of memory due to psychological rather than physiological causes. The memory loss is usually confined to personal information only Typically occurs following traumatic events. May involve motivated forgetting of events, poor storage of information during events due to overarousal, or avoidance of emotions experience during an event. Help the individual remember traumatic events and accept them. Notes: 1)Partial or total forgetting of past experience without a biological cause. 2)Almost always anterograde (After the trauma) blocking out a period of time after psychogenic cause (e.g. stress / trauma) 3)Memory loss is often selective. 4)Relative indifference to loss of memory. 5)Remain well oriented to time and place. 17 P a g e

18 (B) Dissociative Fugue: Symptoms Etiology Treatment Person suddenly moves away from home and assumes an entirely new identity, with no memory of previous identity Fugue states usually occur in response to some stressor, but because they are extremely rare, little is known about etiology Psychotherapy to help the person identify the stressors leading to the fugue state and learn better coping skills Notes: 1) Amnesia + sudden, unexpected trip away from home. 2) Often involves the creation of a new identity. 3) Fugue state usually ends abruptly then amnesic for events during the fugue. 18 P a g e

19 (C) Dissociative Identity Disorder: (Obsession disorder) Symptoms Etiology Treatment Presence of two or more separate identities in the same individual. These personalities may have different ways of speaking and relating to others and can have different ages and genders Alters (Different identity) may be created by people under conditions of extreme stress, often child abuse. Self-hypnosis may be involved. OR Created inadvertently by therapists Long-term psychotherapy to discover functions of the personalities and to assist in integration. (D) Depersonalization Disorder: (Derealization) 1) People with this disorder have frequent episodes in which they feel detached from their own mental processes or bodies, as if they are outside observers of themselves. (Doubling phenomena). 2) Occasional experiences of depersonalization are common, especially when people are sleep deprived. 3) Depersonalization Disorder is only diagnosed when they are so frequent and distressing that they interfere with an individual s ability to function 19 P a g e

20 Dissociative Disorders (Summary) Dissociative Identity Disorder Dissociative Fugue Dissociative Amnesia Depersonalization Disorder Separate, multiple personalities in the same individual. The person moves away and assumes a new identity, with amnesia for the previous identity. The person loses memory of important personal facts, including personal identity, for no apparent organic cause Frequent episodes where individual feels detached from his or her mental state or body 20 P a g e

21 Eating disorders Anorexia nervosa and bulimia nervosa: The patient shows abnormal behavior associated with food despite normal appetite. They use the food to regulate there emotions. Anorexia nervosa : (Under wieght) (A) Restricting type (e.g., excessive dieting): 1) 50% of patients 2) They refrain from food. (B) Binge eating purging type (e.g., excessive dieting) + 1) Binge-eating: Consuming large quantities of high calorie food at one time. 2) Purging: Vomiting, or misuse of laxatives, diuretics, and enemas. 21 P a g e

22 Bulimia nervosa: (Normal average of weight or above average) 1) The purging type Binge eating and purging. 2) Non-purging type Binge eating and excessive dieting or exercising but no purging. The purging type of either anorexia nervosa or bulimia nervosa is associated with electrolyte abnormalities. Specific electrolyte abnormalities are related to the type of purging seen. (A) Low potassium (hypokalemia), low sodium, and high bicarbonate (metabolic alkalosis) levels are seen with vomiting or diuretic abuse. (B) Low potassium, high chloride, and low bicarbonate levels (together known as hyperchloremic metabolic acidosis) are seen with laxative abuse. Eating disorders are more common in women, in higher socioeconomic groups, and in the United States (compared with other developed countries). 22 P a g e

23 Physical charastaristic: Anorexia nervosa Bulimia nervosa 1)Extreme weight loss : 1)Relatively normal body weight (15% or more of normal body weight) 2)Amenorrhea: 2)Esophageal varices caused by repeated (3 or more consecutive missed vomiting menstrual periods) 3) Electrolyte disturbances 3) Tooth enamel erosion due to gastric acid in the mouth 4) Hypercholesterolemia 4) Swelling or infection of the parotid glands 5) Mild anemia and leukopenia 5) Metacarpal-phalangeal calluses (Due to acid burn will result in hypertrophied keratinization. (Russell sign) from the teeth because the Hand is used to induce gagging 6) Lanugo: (downy body hair on the trunk) 7) Melanosis coli: (blackened area of the colon if there is laxative abuse) 8) Osteoporosis 9) Cold intolerance 6) Electrolyte disturbances 7) Menstrual irregularities 10) Syncope 23 P a g e

24 Psycological charastaristic: Anorexia nervosa 1)Refusal to eat despite normal appetite because of an overwhelming fear of Being obese 2)Belief that one is fat when very thin ( Distortion in body image) 3)High interest in food related activities (Ex. cooking), Without eating. 4)Lack of interest in sex 5)Was a "perfect child"(ex.good student) 6)Interfamily conflicts (Ex. patient's problem draws attention away from parental marital problem or an attempt to gain control to separate from the mother) 7)Excessive exercising (hypergymnasia) Bulimia nervosa 1)Binge eating (in secret) of high-calorie foods, followed by vomiting or other purging behavior to avoid weight gain 2)Depression 3) Hypergymnasia 24 P a g e

25 Manegment: Anorexia nervosa 1)Hospitalization 2)Family therapy 3)Group psychotherapy Bulimia nervosa 1)Cognitive and behavioral therapies 2)Average to high doses of antidepressants, particularly SSRIs 3)Group psychotherapy Many thanks for Zakaria Al Refai. Best of luck Your colleague: Dana Entabi 25 P a g e

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