1<br />DISSOCIATIVE DISORDERS<br />
2<br />Somatoform Disorders<br />These a group of mental disorders characterized by physical symptoms<br />They do not hav...
3<br />Six major  DSM-IV classifications<br />Somatization disorder<br />Conversion disorder<br />Hypochondriasis<br />Bod...
4<br />DDX:  <br />Major differential diagnosis involves the possibility that the patient truly has a an unidentified unde...
5<br />Somatoform disorders are more common  in female except for Hypochondrasis, which is found equally in both<br />50% ...
6<br />Treatment can control symptoms but they often return<br />Useful factors in treatment<br />Formation of a good doct...
7<br />Somatization Disorder <br />Multiple vague physical symptom <br />Nausea<br />Dyspnea<br />Tiredness<br />Menstrual...
8<br />25 year-old woman has a history of unclear somatic complaints.  She tells you that she has consulted many doctors b...
9<br />Conversion Disorder<br />Abrupt, dramatic loss of motor or sensory function or organ of special sense<br />Motor Pr...
10<br />Sensory Presentation<br />Paresthesias (abnormal sensations)<br />anesthesias<br />Visual problems<br />Occurrence...
11<br />Course and Prognosis<br />Most patients show Sx remission in less than 1 month<br />Sometimes immediately after hy...
12<br />Hypochondriasis<br />Exaggerated concern with health and illness<br />More common in middle and old age<br />Equal...
13<br />Body Dysmorphic Disorder<br />Patient is preoccupied with a defect in appearance [but has a normal appearance]<br ...
14<br />Pain Disorder<br />Patient experiences intense, prolonged pain with no physical cause or not explained completely ...
15<br />Usually onset is in the 30s and 40s<br />Disorder can be disabling – addiction to pain medication<br />Anti-depres...
16<br />Factitious Disorder<br />Also called Munchausen Syndrome<br />Mental or physical illness or induced physical illne...
17<br />Common Sx:<br />Abdominal pain<br />Blood in urine<br />Induction of tachycardia<br />Fever<br />Skin lesions<br /...
18<br />Factitious Disorder by proxy<br />Induction of illness in another person<br />Usually a child by parent<br />Some ...
19<br />Malingering<br />Simulation of physical or mental illness for financial or other gain<br />Patient avoids medical ...
20<br />Dissociative Disorders<br />Four types of patient Presentation<br />A 20-year-old woman cannot remember any of the...
21<br />A 32-year-old woman discovers clothes in her closet that she has no memory of buying and that are quite different ...
22<br />The four major types of dissociative disorders are:<br />Dissociative amnesia<br />Dissociative fugue<br />Dissoci...
23<br />DDX:<br />Head injury<br />Substance abuse<br />Seizure disorder<br />Sequelae of electro-convulsive therapy<br />...
24<br />Post-traumatic stress disorder and malingering are the psychological differentials to think about<br />Some cultur...
25<br />Dissociative Amnesia<br />Patient is not able to remember important information about oneself<br />It is uncommon ...
26<br />Hypnosis and sodium amorbarbital interviews are to recover the lost traumatic memories<br />Long-term psychotherap...
27<br />Dissociative Fugue<br />Sudden inability to remember important information about oneself with leaving home and ass...
28<br />Hypnosis and sodium amobarbital interviews is used<br />Usually resolves within days --- occasionally last years<b...
29<br />Dissociative Identity Disorder<br />Also called Multiple Personality Disorder<br />Patients have at least two sepa...
30<br />Mild forms may resemble borderline personality disorder or schizophrenia<br />Malingering must be ruled out[when t...
31<br />In some cases, integration of the personalities using insight-oriented psychotherapy with or without hypnosis<br /...
32<br />Depersonalization Disorder<br />Recurrent and persistent feeling of detachment from one’s own body or social situa...
33<br />In transient form, occurs in many people<br />There is no sex difference<br />Traumatic event in childhood or adol...
34<br />Starts most often between 15 and 30 years of age<br />Occurs episodically and commonly continues for many years<br />
35<br />What are the characteristics of Paraphilias?<br />Preferential use of unusual objects of sexual desire or engageme...
Paraphilias, Gender Identity Disorder, and Homosexuality<br />36<br />
37<br />Types of Paraphilias<br />Pedophilia<br />Voyeurism<br />Exhibitionism<br />Fetishism<br />Frotteurism<br />Necrop...
38<br />Pedophilia<br />Preferred method of sexual gratification is to engage in sexual activity with children of the oppo...
39<br />Voyeurism<br />Obtaining sexual satisfaction from secretly watching people undressing or engaging in sexual activi...
40<br />Exhibitionism <br />Exposing the genitals to unsuspecting people in a manner that shocks them<br />A typical patie...
41<br />Fetishism <br />Sexual preference for inanimate objects, such as women’s gloves, shoes, feet, etc.<br />Typical pa...
42<br />Frotteurism <br />Sexual gratification is obtained from rubbing the penis against a non-consenting, unaware woman<...
43<br />Necrophilia<br />Sexual satisfaction is obtained from sexual activity with corpses<br />Typical patient<br />32 y/...
44<br />Masochism and Sadism<br />Obtaining sexual pleasure from receiving (masochism) or causing (sadism) physical suffer...
45<br />Telephone Scatologia<br />Deriving sexual pleasure from calling unsuspected women and engaging them in sexually ex...
46<br />Zoophilia<br />Preferred sexual activity is with animals<br />Can be dangerous because sexually aroused animals ar...
47<br />Treatment<br />Psychoanalytically oriented psychotherapy<br />Aversive conditioning (electric shock)<br />Anti-and...
48<br />Gender Identity Disorder<br />Patient sense of being male or female <br />Commonly called Trans-sexuality <br />Ex...
49<br />Sex surgery is rarely performed now because in past the depression and psychological symptoms were not relieved fo...
50<br />Typical patient<br />28y/o male patient tells you that ever since childhood he has felt like he was “a woman born ...
51<br />Homosexuality 	<br />Likes people of the same sex as a sexual and love object<br />Most have experienced heterosex...
52<br />Indicators of a Genetic  Etiology<br />High concordance rate in monozygotic twins than dizygotic twins<br />Marker...
53<br />
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Psych Lecture 7 Somatoform.1ppt

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Psych Lecture 7 Somatoform.1ppt

  1. 1. 1<br />DISSOCIATIVE DISORDERS<br />
  2. 2. 2<br />Somatoform Disorders<br />These a group of mental disorders characterized by physical symptoms<br />They do not have corresponding organic pathology<br />Patients truly believes that they have a physical problem<br />
  3. 3. 3<br />Six major DSM-IV classifications<br />Somatization disorder<br />Conversion disorder<br />Hypochondriasis<br />Body dysmorphic disorder<br />Pain disorder<br />Undifferentiated somatoform disorder (combo of other somatoform disorders)<br />
  4. 4. 4<br />DDX: <br />Major differential diagnosis involves the possibility that the patient truly has a an unidentified underlying physical ailment <br />CNS illness<br />Multiple sclerosis<br />Dementia<br />Epilepsy<br />Brain tumor<br />Connective tissue disorder<br />Lupus<br />Endocrine disorder<br />Thyroid dysfunction<br />hypoglycemia<br />
  5. 5. 5<br />Somatoform disorders are more common in female except for Hypochondrasis, which is found equally in both<br />50% of patients also have another mental disorder [depression and anxiety]<br />Patient unconsciously expresses an unacceptable emotion as a physical symptom so he does not have to deal with the emotion [primary gain]<br />Symptoms allows the patient to get attention from others or avoid responsibility [secondary gain]<br />
  6. 6. 6<br />Treatment can control symptoms but they often return<br />Useful factors in treatment<br />Formation of a good doctor - patient relationship <br />Individual and group psychotherapy, hypnosis and behavioral relaxation therapy<br />Identification and reduction of patient’s life that may exacerbate the symptoms<br />Reducing the secondary gain associated with the symptoms <br />Medications are useful for treatment of comorbid psychiatric illness<br />
  7. 7. 7<br />Somatization Disorder <br />Multiple vague physical symptom <br />Nausea<br />Dyspnea<br />Tiredness<br />Menstrual irregularities<br />Occurrence<br />Onset before 30 years of age<br />More common in lower socioeconomic groups<br />10% of patients of primary care practitioners<br />Course of disorder is chronic and lifelong<br />Symptoms are increased by stressful life events<br />
  8. 8. 8<br />25 year-old woman has a history of unclear somatic complaints. She tells you that she has consulted many doctors but that they are unable to help her<br />
  9. 9. 9<br />Conversion Disorder<br />Abrupt, dramatic loss of motor or sensory function or organ of special sense<br />Motor Presentation<br />Paralysis [which shifts to different areas of the body]<br />Seizures, which are often bizarre<br />Globus hystericus (lump in the throat)<br />
  10. 10. 10<br />Sensory Presentation<br />Paresthesias (abnormal sensations)<br />anesthesias<br />Visual problems<br />Occurrence<br />More common in adolescents and young adults<br />Patients from rural areas<br />Psychiatrically unsophisticated patients<br />
  11. 11. 11<br />Course and Prognosis<br />Most patients show Sx remission in less than 1 month<br />Sometimes immediately after hypnosis Sx go away<br />25% of patients have recurrent episodes [ when stressful life events occur<br />
  12. 12. 12<br />Hypochondriasis<br />Exaggerated concern with health and illness<br />More common in middle and old age<br />Equal in both sexes<br />Episodic periods of Sx<br />Each lasting up to a few years<br />Interspersed with periods when few Sx are present<br />50% of patients improve over course of their lives<br />
  13. 13. 13<br />Body Dysmorphic Disorder<br />Patient is preoccupied with a defect in appearance [but has a normal appearance]<br />If defect present it is usually very minor<br />Most often complaint involves slight flaws of the face and head<br />Onset usually in the late teens<br />Chronic course with variable levels of concern over time about the physical feature causing distress<br />Plastic surgery or other medical treatment rarely alleviates Sx<br />
  14. 14. 14<br />Pain Disorder<br />Patient experiences intense, prolonged pain with no physical cause or not explained completely by physical cause or not explained completely by physical disease<br />Can be acute (lasting less than 6 months)<br />Chronic is lasting more than a6 months<br />Often coexists with a general medical condition<br />
  15. 15. 15<br />Usually onset is in the 30s and 40s<br />Disorder can be disabling – addiction to pain medication<br />Anti-depressants (SSRIs) may be useful<br />
  16. 16. 16<br />Factitious Disorder<br />Also called Munchausen Syndrome<br />Mental or physical illness or induced physical illness to gain attention from medical personnel<br />Patient often have worked in the medical field and have specific knowledge of how to imitate medical illness effectively<br />
  17. 17. 17<br />Common Sx:<br />Abdominal pain<br />Blood in urine<br />Induction of tachycardia<br />Fever<br />Skin lesions<br />Seizures<br />
  18. 18. 18<br />Factitious Disorder by proxy<br />Induction of illness in another person<br />Usually a child by parent<br />Some patients report a history of childhood abuse or neglect<br />
  19. 19. 19<br />Malingering<br />Simulation of physical or mental illness for financial or other gain<br />Patient avoids medical treatment and “recovers” as soon as the gain is realized<br />
  20. 20. 20<br />Dissociative Disorders<br />Four types of patient Presentation<br />A 20-year-old woman cannot remember any of the events of a car accident in which she was driving had her sister was killed.<br />A 44-year-old man has been living and working in a town 500 miles from his home for over 2 years. He has no memory of his life before this time.<br />
  21. 21. 21<br />A 32-year-old woman discovers clothes in her closet that she has no memory of buying and that are quite different from the clothes that she usually wears.<br />A 45-year-old woman tells you that she often feels like an observer rather than a participant in her life.<br />
  22. 22. 22<br />The four major types of dissociative disorders are:<br />Dissociative amnesia<br />Dissociative fugue<br />Dissociative identity disorder<br />Depersonalization disorder<br />
  23. 23. 23<br />DDX:<br />Head injury<br />Substance abuse<br />Seizure disorder<br />Sequelae of electro-convulsive therapy<br />Sequelae of anesthesia<br />Delirium<br />Dementia<br />
  24. 24. 24<br />Post-traumatic stress disorder and malingering are the psychological differentials to think about<br />Some cultures or religions have perception that altered states of identity, consciousness are seen in concert with certain experiences<br />
  25. 25. 25<br />Dissociative Amnesia<br />Patient is not able to remember important information about oneself<br />It is uncommon and occurs more often in young adults and in women<br />It is used as defense mechanisms for denial and repression after an emotionally traumatic event<br />
  26. 26. 26<br />Hypnosis and sodium amorbarbital interviews are to recover the lost traumatic memories<br />Long-term psychotherapy to deal with the recovered material<br />Amnesia after acute stress may resolve in minutes or may last for years<br />
  27. 27. 27<br />Dissociative Fugue<br />Sudden inability to remember important information about oneself with leaving home and assuming a different identity<br />Patient is usually not aware that he has done this<br />Has a rare occurrence and is associated with a history of excessive alcohol use<br />While etiology ? Most have a traumatic event in recent past<br />
  28. 28. 28<br />Hypnosis and sodium amobarbital interviews is used<br />Usually resolves within days --- occasionally last years<br />
  29. 29. 29<br />Dissociative Identity Disorder<br />Also called Multiple Personality Disorder<br />Patients have at least two separate personalities<br />One ‘alter’ usually dominates the others<br />Most commonly seen in women<br />Not uncommon in mild form<br />Rare in severe form<br />
  30. 30. 30<br />Mild forms may resemble borderline personality disorder or schizophrenia<br />Malingering must be ruled out[when the patient presents in a forensic (legal) context]<br />Early traumatic experience<br />Usually abuse in childhood or adolescence<br />Most commonly associated with incest<br />
  31. 31. 31<br />In some cases, integration of the personalities using insight-oriented psychotherapy with or without hypnosis<br />Antidepressants, antianxiety and anticonvulsant agents may be helpful<br />Often chronic and associated with other psychiatric symptoms [depression and anxiety]<br />
  32. 32. 32<br />Depersonalization Disorder<br />Recurrent and persistent feeling of detachment from one’s own body or social situation [ if involves environment its called derealization disorder]<br />Sx often present in psychiatric disorders such as schizophrenia, depression, anxiety and histrionic personality disorder<br />
  33. 33. 33<br />In transient form, occurs in many people<br />There is no sex difference<br />Traumatic event in childhood or adolescence may be the etiology<br />Anti-anxiety and SSRIs may be useful<br />Psychotherapy is rarely useful<br />
  34. 34. 34<br />Starts most often between 15 and 30 years of age<br />Occurs episodically and commonly continues for many years<br />
  35. 35. 35<br />What are the characteristics of Paraphilias?<br />Preferential use of unusual objects of sexual desire or engagement in unusual sexual activity<br />Behavior should occur over a period of at least 6 months<br />Behavior causes impairment in occupational or social functioning<br />Primary disturbance in mood causing subjective distress and occupational or social problems<br />These individuals act on their fantasies – if they don’t it is not Paraphilia<br />
  36. 36. Paraphilias, Gender Identity Disorder, and Homosexuality<br />36<br />
  37. 37. 37<br />Types of Paraphilias<br />Pedophilia<br />Voyeurism<br />Exhibitionism<br />Fetishism<br />Frotteurism<br />Necrophilia<br />Sexual Sadism and Masochism<br />Telephone Scatologia<br />Zoophilia<br />
  38. 38. 38<br />Pedophilia<br />Preferred method of sexual gratification is to engage in sexual activity with children of the opposite or same sex<br />Up to 20% of children have been sexually abused <br />It is the most common Paraphilia<br />Typical patient: <br />A 45 y/o scoutmaster is arrested after an 11 y/o boy scout complains that the scoutmaster fondled him during a photography session.<br />
  39. 39. 39<br />Voyeurism<br />Obtaining sexual satisfaction from secretly watching people undressing or engaging in sexual activity<br />Typical patient<br />A 28 y/o man is repeatedly arrested for using binoculars to spy on women in a neighboring apartment building<br />
  40. 40. 40<br />Exhibitionism <br />Exposing the genitals to unsuspecting people in a manner that shocks them<br />A typical patient:<br />34 Y/O MAN IS REPEATEDLY ARRESTED FOR UNZIPPING HIS TROUSERS AND BARING HIS PENIS TO WOMEN ON THE SUBWAY<br />
  41. 41. 41<br />Fetishism <br />Sexual preference for inanimate objects, such as women’s gloves, shoes, feet, etc.<br />Typical patient:<br />A 30 y/o man commonly masturbates while stroking a woman’s high-heeled shoes<br />Transvestic fetishism<br />Sexual gratification obtained from wearing women’s clothing ….. Most common is lingerie<br />A 23 y/o man reports that to become aroused he must wear a woman’s nightgown, when ever he has sex with his wife<br />
  42. 42. 42<br />Frotteurism <br />Sexual gratification is obtained from rubbing the penis against a non-consenting, unaware woman<br />Typical patient <br />29 y/o man is arrested for masturbating by rubbing up against a woman in a crowded subway car. <br />
  43. 43. 43<br />Necrophilia<br />Sexual satisfaction is obtained from sexual activity with corpses<br />Typical patient<br />32 y/o man is arrested for murder after he confesses to killing a young women to have sex with her<br />
  44. 44. 44<br />Masochism and Sadism<br />Obtaining sexual pleasure from receiving (masochism) or causing (sadism) physical suffering or humiliation<br />Typical patient<br />46 y/o stockbroker regularly pays a woman to beat and humiliate him<br />
  45. 45. 45<br />Telephone Scatologia<br />Deriving sexual pleasure from calling unsuspected women and engaging them in sexually explicit conversations<br />Typical patient<br /> 32 y/o man makes anonymous telephone calls to teenager girls after school hours so that he can talk to them about sex<br />
  46. 46. 46<br />Zoophilia<br />Preferred sexual activity is with animals<br />Can be dangerous because sexually aroused animals are often unpredictable<br />Typical patient<br />A 18 y/o man prefers to have sexual intercourse with his female dog<br />
  47. 47. 47<br />Treatment<br />Psychoanalytically oriented psychotherapy<br />Aversive conditioning (electric shock)<br />Anti-androgens and female sex hormones used for paraphilias characterized by hypersexuality<br />Factors for best prognosis:<br />Ability to have sexual intercourse in the absence of the paraphilia<br />Presence of guilt about the paraphilia<br />Factors for worse prognosis <br />Referral by police rather than self<br />Younger age of activity onset <br />
  48. 48. 48<br />Gender Identity Disorder<br />Patient sense of being male or female <br />Commonly called Trans-sexuality <br />Expression of one’s gender identity in society<br />Age gender identity develops is between 2 and 3 years of age<br />Must R/O schizophrenia, serious distress homosexuality <br />More common in man<br />Can be diagnosis in childhood<br />Many patient obtain sex hormones to help with secondary characteristics<br />
  49. 49. 49<br />Sex surgery is rarely performed now because in past the depression and psychological symptoms were not relieved following surgery<br />Prognosis <br />Often chronic, lifelong distress<br />Depression with risk of suicide<br />
  50. 50. 50<br />Typical patient<br />28y/o male patient tells you that ever since childhood he has felt like he was “a woman born into the body of a man”. He hates his penis and feels like it does not belong to him. He is sexually attracted to heterosexual men, prefers to dress in women’s clothes, and would like to have a sex operation. <br />
  51. 51. 51<br />Homosexuality <br />Likes people of the same sex as a sexual and love object<br />Most have experienced heterosexual sex<br />50 – 75% have children<br />DSM IV see it as a normal variant of sexual expression<br />Is considered a dysfunction when the discomfort about sexual preference is pronounced (Sexual disorder NOS) <br />These patients may become chronically depressed<br />
  52. 52. 52<br />Indicators of a Genetic Etiology<br />High concordance rate in monozygotic twins than dizygotic twins<br />Markers on the X chromosome<br />
  53. 53. 53<br />

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