This document discusses somatoform disorders and dissociative disorders. It defines somatoform disorders as mental illnesses where patients experience physical symptoms that cannot be explained medically. It outlines the DSM-IV and DSM-V classifications of somatoform disorders including somatic symptom disorder. Dissociative disorders involve lack of connection in consciousness and identity. Dissociative disorders discussed include dissociative amnesia, dissociative fugue, and dissociative identity disorder. Treatment options mentioned include various forms of psychotherapy and drug therapy.

2. SOMATOFORM DISORDERS
Introduction
In the word, 'Somatoform' prefix 'soma' came from
Greek word, 'body' It is a mental illness in which
multiple bodily signs and symptoms are elicited but, the
medical evaluation does not reveal any abnormalities.
Patients will visit a number of doctors (Doctor's
shopping), when the doctor says that there is no health
problems, then the patient might get face issues like
frustration, anxiety and depression.

3. DSM-IV Classification of Somatoform Disorder
•Somatization disorders (or) Briquet's syndromes
Multiple organ system involvement is present.
•Conversion disorders: Neurological complaints.
•Hypochondriasis: Worried about being sick with a
particular illness rather than to focus on physical
symptoms (now. Hypochondriasis is termed as
illness Anxiety disorder in DSM V)

4. •Body dysmorphic disorders Dissatisfaction with any of
the body part (Now, Body dysmorphic disorder has been
shifted to Obsessive Disorders in the DSMV)
•Persistent somatoform pain disorders Pain is the main
complaint (Now, Persistent somatoform pain disorder is
the part of Somatic Symptom Disorder in DSM V)
•Undifferentiated somatoform disorder
•Somatoform disorder not otherwise specified:

5. DSM V Classification of Somatic Symptoms Related
Disorders
•Somatic symptom disorder
•Illness anxiety disorder (hypochondriasis)
•Conversion disorder (functional neurological symptom
disorder)
•Psychological factors affecting other medical conditions
•Factitious disorders

6. •Other specified somatic symptoms and related disorders
(pseudocyesis) condition in which the patient has all
signs and symptoms of pregnancy except for the
confirmation of the presence of a fetus.
•Unspecified somatic symptom and related disorders

7. Somatic Symptom Disorder
Definition
Presence of one or more somatic symptoms which cause
significant personal distress in patient.
EpidemiologyIt begins in teenage usually before 30
years of age It is more common in women. Depression
and anxiety is the common co-morbid illness. The
common personality traits are paranoid, avoidant, self-
defeating and obsessive- compulsive trait.

8. Etiology
•Psychodynamic factors
•Learning theory
•Social/cultural factors
•Biological factors
•Genetic factors
•Cytokines
Differential Diagnosis
•True medical illness
Psychiatric disorders such as depression and anxiety Life
stressors with associated psycho physiological symptoms
•Other somatic symptoms-related disorders
•Course of Illness is usually chronic and relapsing in nature.

9. DSM V Diagnostic Criteria
•One or more somatic symptoms which can be distressing
(or) result in the significant disruption of daily life
•Excessive feelings or thoughts or behaviors related to
somatic symptoms (or) which are associated with health
concerns are manifested by at least one of the followings:
Disproportionate and persistent thoughts about
the seriousness of one's symptoms
Persistently high levels of anxiety about health or
symptoms
Excessive time and energy is devoted to these
symptoms or health concerns
•State of being symptomatic persists for more than 6
months

10. Individual appears with many physical symptoms
which occurs over a period of years. It leads to
multiple medical consultations and other attempts for
seeking treatment.
It must cause significant impairment in social,
occupational, or other areas of functioning. In spite of
appropriate investigations done, the symptoms cannot
be fully explained by a known general medical
condition.
The symptoms are not produced intentionally.

11. There will be four pain symptoms which is related to at
least four different sites or functions which are as
follows:
Two gastrointestinal symptoms other than pain
One sexual or reproductive symptom
One pseudoneurological symptom (suggesting a
neurological condition)

12. Treatment
•Nurse has to help the patient to have a regular monthly
visit to the same psychiatrist.
•Advise the patient to avoid the diagnostic investigations.
•Raise awareness of these symptoms being responses to
psychological pressure
•Improve the coping skills/abilities with these symptoms.
•Provide individual or group psychotherapy.
•Assist the patient to express the underlying emotions and
also help the patient to develop alternative strategies to
express feelings of the patient.

13. Nursing Diagnosis
•Ineffective coping skills related to unresolved
psychological conflicts as evidenced by the verbalized
somatic symptoms.
•Anxiety related to extreme concern about physical
illness/symptoms.
•Low self-esteem related to perceived threat to perform
daily functional activities.
•Powerlessness related to perceived lack of ability to
improve the physical health as evidenced by high level
dependency.
•Social isolation related to lack of ability to participate in
social events.
•Interrupted family process related to the assumption of
sick role.

14. DISSOCIATIVE OR
CONVERSION DISORDER

15. Definition-Dissociative disorder is consciousness,
defined as lack of integration of ,memory and identity
History- 19th Century Mr. Pierre Janet, French
Physician and Psychologist is the first person to
identify the concept of dissociation
1962 - Freud viewed that the dissociation is an active
mechanism of repression.
Epidemiology -Dissociative amnesia (formerly
psychogenic amnesia) s the commonest type of
dissociative disorder. The prevalence of dissociative
fugue is 0.2%, however it is increased during the time
of disaster, accidents and war.

16. Etiology
•Biological/Neurophysiological dysfunction -Amygdala,
Hippocampus, Frontal cortex, Mammillary bodies
(brainstem nuclei on the postero inferior aspect of the
hypothalamus.) and thalamus.
•Psychodynamic factors- Intrapsychic conflict,
sublimation, projection and repression
•Social factors/Learning theory - Non-verbal means of
controlling/managing others
• Behavioral - Reinforcement by Primary Gain Protect
from painful emotional experience
Secondary Gain - Gratifying response of having a sick role

17. Fixation of oedipus complex in the early developmental
stage
Conflicts of sexual drive with reactivation of anxiety in
the fixed stage
Primary defense mechanism
Repression
Secondary defense mechanism
Projection, sublimation, conversion, dissociation
Dissociative disorder

18. Motor symptoms
Involuntary movements
Tics
Blepharospasm
Seizures
Abnormal gait Torticollis
Opisthotonus
Falling
Weakness
Aphonia
Astasia-Abasia
Paralysis
Sensory deficits
Anaesthesia of extremities
Blindness
Midline
Anaesthesia
Tunnel vision
Deafness
Visceral symptoms
Psychogenic vomiting
Pseudocyesis
Urinary retention
Diarrhea
Globus hystericus
Swooning or syncope
Clinical Features

19. Differential Diagnosis
•Delirium/Dementia
•Epilepsy
•Amnesia with general medical disorder
•Transient Global Amnesia( is an episode of confusion that
comes on suddenly in a person who is otherwise alert)
•Substance induced amnesia
•Wernicke-Korsakoff syndrome(is a neurological disorder
caused by the lack of thiamine (vitamin B1))
•Acute stress
•Somatoform/Somatization/Conversation disorder
•Malingering(pretend to be ill in order to escape duty or
work.)

20. Course and Prognosis
•Usually acute onset
•Recovery is complete, few relapses might be there
•Duration is prolonged if dissociation is due to secondary
gain
•Symptoms might terminate abruptly
•Prognosis is good when onset is acute and the individual has
above average intelligence.

21. Dissociative Amnesia
It is the
commonest type of dissociative disorder. It is most
commonly seen in young adults and it has been
observed that females are more affected as compared to
males. Mostly dissociative amnesia has the following
stages:
•Before amnesia: Stressor or traumatic life event
•During amnesia: Clouding of consciousness
•Post amnesia: Aware of disturbances in memory

22. Types of Dissociative Amnesia
•Localized Amnesia: Unable to recall for specific time period
after the event
•Selective Amnesia: Unable to recall certain incidents with
traumatic event
•Continuous Amnesia: Unable to recall from a specific time
till date
•Generalized Amnesia: Unable to recall entire lifetime
incidence including the personal identity
•Systematized Amnesia: Unable to recall events with specific
category (Eg. Any particular person/event)

23. Dissociative Fugue
It is characterized by episodes of wandering away from
home. During the wandering, individual assumes new
identity along with complete amnesia of previous life.
Onset is sudden with presence of stress. Termination is
abrupt with remembrance of previous life. Differential
diagnosis includes the complex partial seizure and
temporal lobe epilepsy (in which assumption of new
identity is absent).

24. Multiple Personality (Dissociative Identity) Disorder
Individual is dominated with two or more personalities,
in which one personality is manifested at a time. One
personality is not aware about the other personality
(Amnesia is present between the personalities). Onset
and termination of personality is sudden in nature.

25. Treatment
•Behavior therapy
Aversion therapy - Pressure in tragus of ear
Psychotherapy with Abreaction (Bringing to conscious
awareness/thoughts/memories for first time)
Hypnosis
Free association
Intravenous barbiturates (Thiopentone/ Diazepam)
•Supportive psychotherapy
•Insight-oriented supportive or behavior therapy
•Psychodynamic psychotherapy
•Psychoanalysis
•Drug therapy
Short acting Barbiturate (Amobarbital) and
Benzodiazepines