Transcript gagging throat

SOMATOFORM DISORDERS
Aws Khasawneh, MD.
Characteristics of the Somatoform
Disorders
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Somatization: the expression of psychological pain
through physical symptoms or concerns.
Unexplained physical symptoms or bodily
preoccupations.
Somatization Disorder, Conversion Disorder, Pain Disorder,
Undifferentiated Somatoform Disorder: experiencing pain or
physical symptoms with no apparent medical basis
 Hypochondriasis: preoccupation with having a serious medical
condition or disease
 Body Dysmorphic Disorder: preoccupation with a perceived
serious defect in appearance.
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Characteristics of the Somatoform
Disorders
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Psychological factors are associated with the
initiation or exacerbation of Sx
Diagnoses of exclusion – Dx requires you to rule out:
Underlying general medical causes
 Other psychological disorders, e.g. an Anxiety or Mood
Disorder
 Intentional feigning or production of Sx, as in Factitious
Disorder (motivated by a desire to assume the sick role), or
Malingering (motivated by external incentives for behavior,
e.g. economic gain, avoiding legal responsibility)

Somatization Disorder: Diagnostic
Criteria
History of physical symptoms:
 beginning
before age of 30
 occurring over several years
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Must include
 Four
different pains
 Two gastrointestinal symptoms
 One sexual/reproductive symptom
 One pseudo-neurological symptom
 resulting
in TX being sought or significant
impairment in functioning
Somatization Disorder:
Facts & Figures
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Prevalence: 0.2-2% among women; less than 0.2%
among men.
Course: chronic, fluctuating disorder; rarely remits
completely
Onset: adolescence; before 25 years old
Most common among those who are: unmarried,
female, lower educated & from lower SES groups
Family history of depression, substance abuse and
antisocial personality disorder.
Somatization Disorder:
Treatment Considerations
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Long term supportive psychotherapy: therapist can
provide an important, reassuring, sympathetic
relationship; use brief, widely-spaced sessions
Antidepressants
Use of a “gate-keeper” physician
Work in tandem with a primary care physician &
psychiatrist
Conversion Disorder:
Facts & Figures
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More common in:
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rural populations
lower SES
less medically/psychologically sophisticated
women than men (2-10x)
In women, sx are much more common on the left than right side
of the body
11-500 out of 100,000 in general population meet criteria for
conversion disorder
3% of outpatient referrals to mental health clinics
1-14% of medical/surgical inpatients
Onset: late childhood through early adulthood; rarely before 10
or after 35
Conversion Disorder:
Diagnostic Criteria
A.
B.
C.
D.
E.
F.
One or more Sx or deficits affecting voluntary motor or sensory
functioning and indicative of a neurological or other medical condition
Psychological factors are associated with the Sx – the initiation or
exacerbation of Sx is preceded by conflicts or stressors
The Sx is not intentionally feigned or produced, as in Factitious
Disorder or Malingering
The Sx cannot be fully explained by a general medical condition, the
effects of a substance, or a culturally sanctioned behavior or
experience
Sx cause significant distress or impairment in functioning or warrant
medical attention
The Sx 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
Conversion Disorder: Theory
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Psychoanalytic:
 The person experiences a traumatic event, which produces anxiety and
psychological conflict
 Anxiety and unconscious psychological conflict are converted to somatic
symptoms
 Sx provide primary gain (reduce anxiety and keep the conflict out of
awareness)
 Sx provide secondary gain (the person obtains external benefits, such as
attention or sympathy, or evades noxious duties and responsibilities)
Getting sick provides the person an escape from a traumatic situation
Hx of significant stress
Over-involved and over-protective parents
Prior experience with real physical problems
Underlying psychopathology
Conversion Disorder:
Treatment Considerations
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Role of suggestibility – patients can be suggested into & out of Sx
Identify and attend to the traumatic or stressful life event
Address current psychosocial stressors with environmental manipulation,
support, advice, and coping skills
Reduce any reinforcing or supportive consequences from the conversion
Sx
For acute Sx: positive expectation for recovery; a face-saving way for
the patient to recover, e.g. physical therapy
For chronic Sx: physical rehabilitation, suggestion, & psychotherapy
Work closely with a medical doctor and psychiatrist
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.
3 Types of Pain Disorder
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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, e.g.
low back, sciatic, pelvic, headache, chest, joint,
abdominal, throat, urinary
Pain Disorder Associated with Both Psychological
Factors and a General Medical Condition: most
common
Pain Disorder: Specifiers
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Acute: duration less than 6 months
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Chronic: duration 6 months or longer
Pain Disorder:
Treatment Considerations
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Pain management: teach techniques for coping with pain; use of
analgesic, anti-inflammatory, and antidepressant medications
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.
Hypochondriasis:
Diagnostic Criteria
A. Preoccupation with fear of having or belief that one has a serious
illness, based on misinterpretation of bodily Sx or functions
B. Preoccupation persists despite appropriate medical evaluation,
reassurance, and the person’s not developing the feared disease
C. Preoccupation lasts at least 6 months
D. Preoccupation causes clinically significant distress or impairment in
important areas of functioning
E. Preoccupation is not better accounted for by other disorders, such
as GAD, OCD, Panic Disorder, Major Depression, Separation
Anxiety, or another Somatoform Disorder
Hypochondriasis: Causes
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Faulty interpretation of bodily cues and sensations as
evidence of physical illness
Enhanced sensitivity to, & over-focusing on, physical
sensations and illness cues
Stressful life events
Disproportionate incidence of disease in family
during childhood
Secondary gains associated with the sick role:
decreased responsibility and increased attention
Hypochondriasis: Treatments
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Cognitive behavioral treatment: identifying &
challenging illness-related misinterpretations of
bodily sensations; showing patients how to create Sx
by focusing attention on certain body areas
Stress management
Explanatory therapy: reassurance & education
regarding the source and origins of Sx
Body Dysmorphic Disorder: 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
Body Dysmorphic Disorder:
Common Features
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Constant and excessive use of mirrors
Avoidance of mirrors
Lots of time spent grooming
Lots of grooming rituals
Attempts to hide parts of body
Constantly seeking reassurance about looks, while
discounting feedback
Anxiety or depression about one’s appearance
Body Dysmorphic Disorder:
Facts & Figures
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People with BDD often seek help from
dermatologists and plastic surgeons (rates of BDD
in these settings is 6-15%)
BDD is under-recognized & under-diagnosed in
nonpsychiatric settings
BDD is infrequent in mental health settings
Onset: adolescence and young adulthood
Body Dysmorphic Disorder: Causes
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Defense mechanism of displacement: displacing
underlying psychological conflict and anxiety onto
a body part
Variant of OCD
Culturally-influenced, but not culture-bound
Can you see the difference?
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“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).
Body Dysmorphic Disorder: Treatment
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Pharmacotherapy: SSRI’s at higher doses & for longer
duration
CBT strategies: exposure and response prevention, selfesteem building, modifying distorted thinking, and coping
strategies
MALINGERING
The intentional production of false or grossly exaggerated physical
or psychological symptoms, motivated by external incentives.
Examples of the incentives:
avoiding work
obtaining financial compensation
avoiding military duty
evading criminal prosecution
obtaining drugs
Malingering vs. Factitious Disorder
In malingering, the motivation for symptom production is an
external incentive whereas in factitious disorder the external
incentive is absent. In factitious disorder, there is a need
to maintain the sick role. This is also known as Munchausen’s
syndrome.
Dissociative Disorders
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The category of dissociative disorders includes a wide
variety of syndromes whose common core is an alteration in
consciousness that affects memory and identity (APA, 1994).
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Disorder
Dissociative Amnesia
Symptoms
Loss of memory due to psychological rather than
physiological causes. The memory loss is usually
confined to personal information only
Etiology
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
Treatment
Help the individual remember traumatic events and
accept them
Dissociative Amnesia
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Partial or total forgetting of past experience
without a biological cause
Almost always anterograde – blocking out a period
of time after psychogenic cause (e.g. stress /
trauma)
Memory loss is often selective
Relative indifference to loss of memory
Remain well oriented to time and place
Dissociative Fugue
Symptoms
Person suddenly moves away from home and assumes an
entirely new identity, with no memory of previous identity
Etiology
Fugue states usually occur in response to some stressor, but
because they are extremely rare, little is known about etiology
Treatment
Psychotherapy to help the person identify the stressors leading
to the fugue state and learn better coping skills
Dissociative Fugue
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Amnesia + sudden, unexpected trip away from
home
Often involves the creation of a new identity
Fugue state usually ends abruptly – then amnesic
for events during the fugue
Dissociative Identity Disorder
Symptoms
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.
Etiology
Alters may be created by people under conditions of extreme
stress, often child abuse. Self-hypnosis may be involved.
OR
Created inadvertently by therapists
Treatment
Long-term psychotherapy to discover functions of the
personalities and to assist in “integration.”
Depersonalization Disorder
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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.
Occasional experiences of depersonalization are common,
especially when people are sleep deprived.
Depersonalization Disorder is only diagnosed when they are
so frequent and distressing that they interfere with an
individual’s ability to function
Dissociative Disorders (Summary)
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Dissociative Identity
Disorder
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Separate, multiple personalities in the same
individual.
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Dissociative Fugue
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The person moves away and assumes a new
identity, with amnesia for the previous identity.
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Dissociative
Amnesia
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The person loses memory of important personal
facts, including personal identity, for no apparent
organic cause
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Depersonalization
Disorder
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Frequent episodes where individual feels
detached from his or her mental state or body
Eating disorders
anorexia nervosa and bulimia nervosa
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1. In anorexia nervosa and bulimia nervosa, the patient shows abnormal
behavior associated with food despite normal appetite.
2. The subtypes of anorexia nervosa are the restricting type (e.g.,
excessive dieting) and, in 50% of patients, the binge eating purging
type (e.g., excessive dieting plus binge-eating [consuming large quantities
of high calorie food at one time] and purging [e.g., vomiting, or misuse of
laxatives, diuretics, and enemas]).
3. The subtypes of bulimia nervosa are the purging type (e.g., binge
eating and purging) and non-purging type (e.g., binge eating and
excessive dieting or exercising but no purging).
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4. 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.
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5. Eating disorders are more common in women, in higher
socioeconomic groups, and in the United States (compared with other
developed countries).
Physical Characteristics
Anorexia nervosa
Bulimia nervosa
- Extreme weight loss (15% or more of
normal body weight)
- Amenorrhea (three or more consecutive
missed menstrual periods)
- Electrolyte disturbances
- Hypercholesterolemia
- Mild anemia and
- leukopenia
- Lanugo (downy body hair on the trunk)
- Melanosis coli (blackened area of the
colon if there is laxative abuse)
- Osteoporosis
-Cold intolerance
-Syncope
- Relatively normal body weight
- Esophageal varices caused by repeated
vomiting
- Tooth enamel erosion due to gastric acid
in the mouth
- Swelling or infection of the parotid
glands
Metacarpal-phalangeal calluses (Russell
sign) from the teeth because the Hand is
used to induce gagging
- Electrolyte disturbances
- Menstrual irregularities
Psychological Characteristics
Anorexia nervosa
Bulimia nervosa
* Refusal to eat despite normal appetite
because of an overwhelming fear of
Being obese
* Belief that one is fat when very thin
* High interest in food related activities
(e.g., cooking)
* Lack of interest in sex
* Was a "perfect child"(e.g., good student)
* Interfamily conflicts (e.g., patient's
problem draws attention away from
parental marital problem or an attempt to
gain control to separate from the mother)
* Excessive exercising
("hypergymnasia")
* Binge eating (in secret) of high-calorie
foods, followed by vomiting or other
purging behavior to avoid weight gain
* Depression
* "Hypergymnasia"
Management
Anorexia nervosa
Bulimia nervosa
-Hospitalization
-Family therapy
-Group psychotherapy
-Cognitive and behavioral therapies
-Average to high doses of antidepressants,
particularly SSRIs
-Group psychotherapy