Ciencias de la Salud
Behavioral SciencesBehavioral Sciences
Juan Héctor M. Meléndez-Romero. MDJuan Héctor M. Meléndez-Romero. MD
Behavioral SciencesBehavioral Sciences
Somatoform & Dissociative Somatoform & Dissociative DisordersDisorders
Kaplan & sadock`s (Ninth EditionKaplan & sadock`s (Ninth Edition) Chapter 17 Page 643-660Chapter 17 Page 643-660
Somatoform DisordersSomatoform Disorders Broad group of illnesses that have bodily
signs and symptoms.
Soma = body
Encopass mind-body interactions
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Somatoform DisordersSomatoform Disorders
Modified from Kaplan & sadock`s (Ninth EditionModified from Kaplan & sadock`s (Ninth Edition) Chapter 17 Page 643-660Chapter 17 Page 643-660
DSM-IV-TR recognizes five specific disorders:1. Somatization Disorder Physical complaints
2. Conversion Neurological complaints
3. Hypochondriasis “Patient beliefs”
4. Body dismorphic Sx. “Body is defective”
5. Pain Symptoms of pain
Undeterminated
Not otherwise specified
Somatoform DisordersSomatoform Disorders1. Somatization
Characterized by many somaticsymptoms
The symptoms can not be explained on basis of the physical and laboratory examinations.
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Somatoform DisordersSomatoform Disorders
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1. Somatization
Recognized by Pain, Gastrointestinal, Sexual and pseudoneurological symptoms.
Differs of other somotoform disorders because of the multiplicity of the complaints and the multiple organs symptoms.
Somatoform DisordersSomatoform Disorders
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1. Somatization synonimous
Hysteria
Briquet’s syndrome
Somatization Disorder
Somatoform DisordersSomatoform Disorders
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1. Somatization
Lifetime prevalence:women 0.2 to 2.0
%men 0.2
%
Begins before 30-year-old
Inversely related with social status
Somatoform DisordersSomatoform Disorders
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1. Somatization
Coexist with other mental disorders.
2/3 patients has mental disorders:avoidantparanoidself defeatingobssesive – compulsive
symptoms
Somatoform DisordersSomatoform Disorders
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1. Somatization etiology:
Psychosocial Factors:
avoid obligationsexpress emotionssymbolized a feeling or belief
Biological Factors:Attention and cognitive
impairmentsCytokines theory: IL, TNF, IF.
Somatoform DisordersSomatoform Disorders
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1. Somatization Disorder Diagnosis:
A. History of many physical complaints before age 30 years over a period of several years results in impairment of social and occupational functioning.
B. Individual symptoms:1) Four pain symptoms (sites)2) Two gastrointestinal symptoms3) One sexual symptom4) One pseudoneurological symptom
C. Either 1) and 2):1) Each symptom cannot be fully explained
2) In case of medical condition, there are excessive impairment that would be explained.
D. The symptoms are not intentionally produced.
Somatoform DisordersSomatoform Disorders
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1. Differential Diagnosis:
A. Multiple sclerosisB. Myasthenia gravisC. Systemic lupus erythematosusD. AIDSE. HyperparathyroidismF. HyperthyroidismG. Chronic Systemic Infections
Somatoform DisordersSomatoform Disorders
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1. Somatization Treatment:
Primary Care:
Regularly scheduled visits Listen to the somatic complaints and emotional
expressions
Psychiatry evaluation:
Individual or group psychotherapyMedication: AINEs and Placebo ?
Somatoform DisordersSomatoform Disorders
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2. Conversion
Disturbance of bodily functioning
Occurrs in a setting of stress
Produces considerable dysfunction
Somatoform DisordersSomatoform Disorders
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2. Conversion Disorder Definition:
Conversion disorder is characterized by the presence of one or more neurological symptoms that cannot be explain by a known neurological or medical disorder
Somatoform DisordersSomatoform Disorders
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2. Commmon symptoms :
Motor symptoms: Sensory deficits:
Involuntary movements AnesthesiaTics BlindnessBlepharospasm Tunnel visionTorticolis DeafnessSeizures Aphonia Visceral symptoms:Paralysis Psychogenic vomitingWeakness Pseudocyesis
Urinary retentionDiarrhea
Somatoform DisordersSomatoform Disorders
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2. Conversion Disorder Comorbidity:
Depressive disorder
Anxiety disorder
Somatization disorder
Schizopherina
Somatoform DisordersSomatoform Disorders
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2. Conversion Disorder Etiology:
Psychoanalytic factors : conversion of anxiety into a medical symptom.
Learning theory: conditioned learning behavior.
Biological factors: impaired hemispheric communication.
Somatoform DisordersSomatoform Disorders
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Tema XXTema XX
• Concepto XX
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Somatoform DisordersSomatoform Disorders2. Conversion Disorder Diagnosis:
A. One or more symptoms or deficitis affecting voluntary motor or sensory function.
B. Psychological factors are jugded to be associated with the symptoms or deficit because iniciation or exacerbation of symptoms is preceded by conflicts or other stressors.
C. Symptoms are not intentionally produces.D. Symptoms cannot be explained by a general medical
condition.E. The symptoms causes clinically significant distress or
impairment of social, occupational functioning.F. The symtoms are no limited to pain or sexual dysfuntion.
Somatoform DisordersSomatoform Disorders2. Conversion Disorder Treatment:
Psychological therapy: Insight-oriented supportive or behavior therapy.
Hypnosis
Behavioral relaxation therapy
Medical Treatment: Anxiolytic drugs
Somatoform DisordersSomatoform Disorders3. Hypochondriasis
Defined as a person’s preoccupation with the fear of contracting, or belief of heaving a serious disease.
The person misinterpreat bodily symptoms or functions.
Somatoform DisordersSomatoform Disorders3. Hypochondriasis
Etiology.
Low tolerance of, low threshold for physical discomfort
Understandable in terms of a social learning model
Variant of depressive or anxiety disorder.
Somatoform DisordersSomatoform Disorders3. Diagnosis of Hypochondriasis
A. Preoccupation with fear of having, or the idea that one has a serious disease.
B. Preoccupation persist despite appropiated medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity.
D. The preocupation causes clinical distress or impariment of social or functioning areas.
E. Duration at least six months.F. The preoccupation is not better accounted for by
generalized anxiety disorder, separation anxiety,etc.
Somatoform DisordersSomatoform Disorders3. Treatment of Hypochondriasis
Stress reduction
Medical education in chronic illness
Treatment of depressive or mental disorder.
Somatoform DisordersSomatoform Disorders4. Body dhysmophic
Patient’s have a pervasive subjective feeling of Patient’s have a pervasive subjective feeling of ugliness of some aspecto of their appearance ugliness of some aspecto of their appearance despite a normal or nearly normal appearance.despite a normal or nearly normal appearance.
The person’s strong belief or fear that he or she The person’s strong belief or fear that he or she is unattractive or even repulsive.is unattractive or even repulsive.
Somatoform DisordersSomatoform Disorders4. Body dhysmophic
Location of Imagined Defects:Location of Imagined Defects:
HairHair LipsLips NoseNose ChinChin SkinSkin EarsEars EyesEyes PennisPennis Head or faceHead or face ButtocksButtocks Body buildBody build Breast, etc.Breast, etc.
Somatoform DisordersSomatoform Disorders4. Diagnostic Criteria for Body dhysmophic
A.A. Preoccupation with an imagined defect in Preoccupation with an imagined defect in appearance.appearance.
B.B. The preoccupation causes clinically significant The preoccupation causes clinically significant distress or impairment of social or functioning.distress or impairment of social or functioning.
C.C. The preoccupation is not betteraccounted for by The preoccupation is not betteraccounted for by another mental disorder.another mental disorder.
Somatoform DisordersSomatoform Disorders4. Diagnostic Criteria for Body dhysmophic
Relation to plastic surgeryRelation to plastic surgery
Medical treatment: Medical treatment: TryciclicsTryciclicsSSRIsSSRIsIMAO.IMAO.
Somatoform DisordersSomatoform Disorders5. Pain disorder
Presence of pain that is “the focus of clinical Presence of pain that is “the focus of clinical attention”.attention”.
Pain is not fully accounted for by a medical or Pain is not fully accounted for by a medical or neurological condition.neurological condition.
Synonimous: Synonimous: Somatoform pain disorderSomatoform pain disorderPsychogenic painPsychogenic painAtypical pain disorderAtypical pain disorderIdiopathic pain disorderIdiopathic pain disorder
Somatoform DisordersSomatoform Disorders5. Etiology of Pain disorder
Psychodynamic factors.Psychodynamic factors. Intrapsychic conflic: unable to express their feelingsIntrapsychic conflic: unable to express their feelings Displacing the problems to the bodyDisplacing the problems to the body Convinced that they have to sufferConvinced that they have to suffer
Behavioral factors.Behavioral factors.
Interpersonal factors.Interpersonal factors. Means of manipulation.Means of manipulation.
Biological factors.Biological factors. Endorphin deficiency.Endorphin deficiency.
Somatoform DisordersSomatoform Disorders5. Diagnostic Criteria for Pain disorder
A.A. Pain in one or more anatomical sites is the Pain in one or more anatomical sites is the predominant focus in clinical presentation.predominant focus in clinical presentation.
B.B. Pain causes significat distress or clinical Pain causes significat distress or clinical impairment.impairment.
C.C. Psychological factors are jugde to have an Psychological factors are jugde to have an important role in onset, severity, exacerbation and important role in onset, severity, exacerbation and maintenance of pain.maintenance of pain.
D.D. The symptom is not intentionally produced or The symptom is not intentionally produced or feigned.feigned.
E.E. The pain is not better accounted for by a mood, The pain is not better accounted for by a mood, anxiety or psychotic disorder.anxiety or psychotic disorder.
Somatoform DisordersSomatoform Disorders5. Diagnostic Criteria for Pain disorder
Medical Treatment:Medical Treatment: TryciclicsTryciclics SSRI’sSSRI’s
PsychoterapyPsychoterapy
BiofeedbackBiofeedback
Pain Control Programs.Pain Control Programs.
Dissociative DisordersDissociative Disorders
Dissociative DisordersDissociative Disorders
CharacteristicsCharacteristics
• Contradictory representation of the self.
• Produces conflicts with each other.
• They feel that they have not identity
• Can develops sevral identities
Classification Classification
There are four different types:
1. Dissociative amnesia
2. Dissociative Fugue
3. Dissociative Identity dissorder
4. Depersonalization dissorderNot otherwise specified
1. Dissociative amnesia1. Dissociative amnesia
• Amnesia is the Key symptom in this type
• Reffers to the inability to recall information, usually about stressful o traumatic events.
• Affects the recall of general information
1. Dissociative amnesia1. Dissociative amnesia
• Appears in war time or natural disasters.
• Also is related with domestic settings and emergency situations.
• Most patients can not retrive stressful memories.
• DSM-IV diagnostic criteria
2. Dissociative Fugue2. Dissociative Fugue
• The behavior of the patient with dissociative fugue is unusual and dramatic.
• Fugue = The patient travel away his from their customary home and work situations.
• Fails to remember personal data.
2. Dissociative Fugue2. Dissociative Fugue
• Its rare.
• Associated to alcohol abuse
• Desire to withdraw from emotionally painful experiences
• DSM-IV diagnostic criteria
3. Dissociative Identity disorder3. Dissociative Identity disorder
• Sinonimous: Multiple personality disorder
• Chronic disease
• Associated to traumatic events:– Child abuse– Child physical trauma
• There are two or more personalities
3. Dissociative Identity disorder3. Dissociative Identity disorder
• In 1800 Benjamin Rush building earlier clinical report of this problem
• Freud relates with psychodynamic mechanism
• Bleuler relates with schizophrenia.
• The cause is unknown
3. Dissociative Identity disorder3. Dissociative Identity disorder
Signs of multiplicity:
Time distorsion Change in name
Change behavior Use word “we”
Do not recognize personal objetcsAuditive hallucinations
4. Depersonalization disorder4. Depersonalization disorder
• Depersonalization disorder symptoms
• Persistent or recurrent alteration in the perseption of the self.
• His personality is temporally lost.
4. Deprsonalization disorder4. Deprsonalization disorder
• Causes: Neurological disorders
Toxic - metabolic Disorders
Mental dissease
• DSM-IV diagnostic criteria
• Course & Prognosis