1. 1 DISSOCIATIVE DISORDERS

2. 2 Somatoform Disorders These a group of mental disorders characterized by physical symptoms They do not have corresponding organic pathology Patients truly believes that they have a physical problem

3. 3 Six major DSM-IV classifications Somatization disorder Conversion disorder Hypochondriasis Body dysmorphic disorder Pain disorder Undifferentiated somatoform disorder (combo of other somatoform disorders)

4. 4 DDX: Major differential diagnosis involves the possibility that the patient truly has a an unidentified underlying physical ailment CNS illness Multiple sclerosis Dementia Epilepsy Brain tumor Connective tissue disorder Lupus Endocrine disorder Thyroid dysfunction hypoglycemia

5. 5 Somatoform disorders are more common in female except for Hypochondrasis, which is found equally in both 50% of patients also have another mental disorder [depression and anxiety] Patient unconsciously expresses an unacceptable emotion as a physical symptom so he does not have to deal with the emotion [primary gain] Symptoms allows the patient to get attention from others or avoid responsibility [secondary gain]

6. 6 Treatment can control symptoms but they often return Useful factors in treatment Formation of a good doctor - patient relationship Individual and group psychotherapy, hypnosis and behavioral relaxation therapy Identification and reduction of patient’s life that may exacerbate the symptoms Reducing the secondary gain associated with the symptoms Medications are useful for treatment of comorbid psychiatric illness

7. 7 Somatization Disorder Multiple vague physical symptom Nausea Dyspnea Tiredness Menstrual irregularities Occurrence Onset before 30 years of age More common in lower socioeconomic groups 10% of patients of primary care practitioners Course of disorder is chronic and lifelong Symptoms are increased by stressful life events

8. 8 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

9. 9 Conversion Disorder Abrupt, dramatic loss of motor or sensory function or organ of special sense Motor Presentation Paralysis [which shifts to different areas of the body] Seizures, which are often bizarre Globus hystericus (lump in the throat)

10. 10 Sensory Presentation Paresthesias (abnormal sensations) anesthesias Visual problems Occurrence More common in adolescents and young adults Patients from rural areas Psychiatrically unsophisticated patients

11. 11 Course and Prognosis Most patients show Sx remission in less than 1 month Sometimes immediately after hypnosis Sx go away 25% of patients have recurrent episodes [ when stressful life events occur

12. 12 Hypochondriasis Exaggerated concern with health and illness More common in middle and old age Equal in both sexes Episodic periods of Sx Each lasting up to a few years Interspersed with periods when few Sx are present 50% of patients improve over course of their lives

13. 13 Body Dysmorphic Disorder Patient is preoccupied with a defect in appearance [but has a normal appearance] If defect present it is usually very minor Most often complaint involves slight flaws of the face and head Onset usually in the late teens Chronic course with variable levels of concern over time about the physical feature causing distress Plastic surgery or other medical treatment rarely alleviates Sx

14. 14 Pain Disorder Patient experiences intense, prolonged pain with no physical cause or not explained completely by physical cause or not explained completely by physical disease Can be acute (lasting less than 6 months) Chronic is lasting more than a6 months Often coexists with a general medical condition

15. 15 Usually onset is in the 30s and 40s Disorder can be disabling – addiction to pain medication Anti-depressants (SSRIs) may be useful

16. 16 Factitious Disorder Also called Munchausen Syndrome Mental or physical illness or induced physical illness to gain attention from medical personnel Patient often have worked in the medical field and have specific knowledge of how to imitate medical illness effectively

17. 17 Common Sx: Abdominal pain Blood in urine Induction of tachycardia Fever Skin lesions Seizures

18. 18 Factitious Disorder by proxy Induction of illness in another person Usually a child by parent Some patients report a history of childhood abuse or neglect

19. 19 Malingering Simulation of physical or mental illness for financial or other gain Patient avoids medical treatment and “recovers” as soon as the gain is realized

20. 20 Dissociative Disorders Four types of patient Presentation 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. 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.

21. 21 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. A 45-year-old woman tells you that she often feels like an observer rather than a participant in her life.

22. 22 The four major types of dissociative disorders are: Dissociative amnesia Dissociative fugue Dissociative identity disorder Depersonalization disorder

23. 23 DDX: Head injury Substance abuse Seizure disorder Sequelae of electro-convulsive therapy Sequelae of anesthesia Delirium Dementia

24. 24 Post-traumatic stress disorder and malingering are the psychological differentials to think about Some cultures or religions have perception that altered states of identity, consciousness are seen in concert with certain experiences

25. 25 Dissociative Amnesia Patient is not able to remember important information about oneself It is uncommon and occurs more often in young adults and in women It is used as defense mechanisms for denial and repression after an emotionally traumatic event

26. 26 Hypnosis and sodium amorbarbital interviews are to recover the lost traumatic memories Long-term psychotherapy to deal with the recovered material Amnesia after acute stress may resolve in minutes or may last for years

27. 27 Dissociative Fugue Sudden inability to remember important information about oneself with leaving home and assuming a different identity Patient is usually not aware that he has done this Has a rare occurrence and is associated with a history of excessive alcohol use While etiology ? Most have a traumatic event in recent past

28. 28 Hypnosis and sodium amobarbital interviews is used Usually resolves within days --- occasionally last years

29. 29 Dissociative Identity Disorder Also called Multiple Personality Disorder Patients have at least two separate personalities One ‘alter’ usually dominates the others Most commonly seen in women Not uncommon in mild form Rare in severe form

30. 30 Mild forms may resemble borderline personality disorder or schizophrenia Malingering must be ruled out[when the patient presents in a forensic (legal) context] Early traumatic experience Usually abuse in childhood or adolescence Most commonly associated with incest

31. 31 In some cases, integration of the personalities using insight-oriented psychotherapy with or without hypnosis Antidepressants, antianxiety and anticonvulsant agents may be helpful Often chronic and associated with other psychiatric symptoms [depression and anxiety]

32. 32 Depersonalization Disorder Recurrent and persistent feeling of detachment from one’s own body or social situation [ if involves environment its called derealization disorder] Sx often present in psychiatric disorders such as schizophrenia, depression, anxiety and histrionic personality disorder

33. 33 In transient form, occurs in many people There is no sex difference Traumatic event in childhood or adolescence may be the etiology Anti-anxiety and SSRIs may be useful Psychotherapy is rarely useful

34. 34 Starts most often between 15 and 30 years of age Occurs episodically and commonly continues for many years

35. 35 What are the characteristics of Paraphilias? Preferential use of unusual objects of sexual desire or engagement in unusual sexual activity Behavior should occur over a period of at least 6 months Behavior causes impairment in occupational or social functioning Primary disturbance in mood causing subjective distress and occupational or social problems These individuals act on their fantasies – if they don’t it is not Paraphilia

36. Paraphilias, Gender Identity Disorder, and Homosexuality 36

37. 37 Types of Paraphilias Pedophilia Voyeurism Exhibitionism Fetishism Frotteurism Necrophilia Sexual Sadism and Masochism Telephone Scatologia Zoophilia

38. 38 Pedophilia Preferred method of sexual gratification is to engage in sexual activity with children of the opposite or same sex Up to 20% of children have been sexually abused It is the most common Paraphilia Typical patient: A 45 y/o scoutmaster is arrested after an 11 y/o boy scout complains that the scoutmaster fondled him during a photography session.

39. 39 Voyeurism Obtaining sexual satisfaction from secretly watching people undressing or engaging in sexual activity Typical patient A 28 y/o man is repeatedly arrested for using binoculars to spy on women in a neighboring apartment building

40. 40 Exhibitionism Exposing the genitals to unsuspecting people in a manner that shocks them A typical patient: 34 Y/O MAN IS REPEATEDLY ARRESTED FOR UNZIPPING HIS TROUSERS AND BARING HIS PENIS TO WOMEN ON THE SUBWAY

41. 41 Fetishism Sexual preference for inanimate objects, such as women’s gloves, shoes, feet, etc. Typical patient: A 30 y/o man commonly masturbates while stroking a woman’s high-heeled shoes Transvestic fetishism Sexual gratification obtained from wearing women’s clothing ….. Most common is lingerie 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

42. 42 Frotteurism Sexual gratification is obtained from rubbing the penis against a non-consenting, unaware woman Typical patient 29 y/o man is arrested for masturbating by rubbing up against a woman in a crowded subway car.

43. 43 Necrophilia Sexual satisfaction is obtained from sexual activity with corpses Typical patient 32 y/o man is arrested for murder after he confesses to killing a young women to have sex with her

44. 44 Masochism and Sadism Obtaining sexual pleasure from receiving (masochism) or causing (sadism) physical suffering or humiliation Typical patient 46 y/o stockbroker regularly pays a woman to beat and humiliate him

45. 45 Telephone Scatologia Deriving sexual pleasure from calling unsuspected women and engaging them in sexually explicit conversations Typical patient 32 y/o man makes anonymous telephone calls to teenager girls after school hours so that he can talk to them about sex

46. 46 Zoophilia Preferred sexual activity is with animals Can be dangerous because sexually aroused animals are often unpredictable Typical patient A 18 y/o man prefers to have sexual intercourse with his female dog

47. 47 Treatment Psychoanalytically oriented psychotherapy Aversive conditioning (electric shock) Anti-androgens and female sex hormones used for paraphilias characterized by hypersexuality Factors for best prognosis: Ability to have sexual intercourse in the absence of the paraphilia Presence of guilt about the paraphilia Factors for worse prognosis Referral by police rather than self Younger age of activity onset

48. 48 Gender Identity Disorder Patient sense of being male or female Commonly called Trans-sexuality Expression of one’s gender identity in society Age gender identity develops is between 2 and 3 years of age Must R/O schizophrenia, serious distress homosexuality More common in man Can be diagnosis in childhood Many patient obtain sex hormones to help with secondary characteristics

49. 49 Sex surgery is rarely performed now because in past the depression and psychological symptoms were not relieved following surgery Prognosis Often chronic, lifelong distress Depression with risk of suicide

50. 50 Typical patient 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.

51. 51 Homosexuality Likes people of the same sex as a sexual and love object Most have experienced heterosexual sex 50 – 75% have children DSM IV see it as a normal variant of sexual expression Is considered a dysfunction when the discomfort about sexual preference is pronounced (Sexual disorder NOS) These patients may become chronically depressed

52. 52 Indicators of a Genetic Etiology High concordance rate in monozygotic twins than dizygotic twins Markers on the X chromosome

53. 53