S omatoform, dissociative and factitious disorders

1. Somatoform, dissociative and factitious disorders Dr. Rohan Mendonsa Professor of Psychiatry, YMC

2. Basic definitions • Somatoform disorders (Somatic symptom disorders) • Soma- body • pathological concern of individuals with the appearance or functioning of their bodies when there is no identifiable medical condition causing the physical complaints • Dissociative disorders • individuals feel detached from themselves or their surroundings, and reality, experience, and identity may disintegrate • Factitious disorders • a person acts as if they have an illness by deliberately producing, feigning, or exaggeratingsymptoms. • NOT MALINGERING 

3. Historically, both somatoform and dissociative disorders used to be categorized as hysterical neurosis • -in psychoanalytic theory neurotic disorders result from underlying unconscious conflicts, anxiety that resulted from those conflicts and ego defense mechanisms

4. Somatoform Disorders • Types of Somatoform Disorders • Somatization disorder (Somatic symptom disorder) • Hypochondriacal disorder

5. Somatoform Disorders • Somatization disorder • Briquet’s syndrome • patients have a history of many physical • complaints that can not be explained by a medical condition, the complaints are not intentionally produced • Persistent refusal to accept the advice of several doctors- doctor shopping • 20% of patients in primary care • develops during adolescence – • Treatment – pharmacotherapy and reassurance, cognitive-behavioral therapy (CBT)

6. Somatoform Disorders • Hypochondriacal disorder • Persistent preoccupation with the possibility of having one or more serious diseases. • Normal sensations and appearances are often misinterpreted by a patient. Treatment usually involves reassurance and cognitive-behavioral therapy.

7. Dissociative (conversion) Disorders • Partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. • Previously classified as ‘conversion hysteria’. • They are ‘psychogenic’ in origin- associated closely in time with traumatic events, insoluble problems/disturbed relationships.

8. Dissociative (conversion) Disorders • Dissociative amnesia: Amnesia is usually centred on traumatic events, such as accidents or unexpected bereavements. Eg: Soldiers forgetting some events during battle. • Dissociative fugue: amnesia plus an apparently purposeful journey away from home or place of work during which self care is maintained. Occasionally new identity is assumed. • Dissociative stupor: profound diminution or absence of voluntary movement and normal responsiveness- Motionless for long time.

9. Dissociative (conversion) Disorders • Trance and possession disorders: • individual acts as if taken over by another personality, spirit, deity or ‘force’, repeated set of movements, postures and utterances; occur outside culturally accepted situations. • Dissociative disorders of movement and sensation:loss of or interference with movements or loss of sensations; the disability helps the patient to escape from an unpleasant conflict, or to express dependency or resentment indirectly;

10. Dissociative Disorders • Dissociative Identity Disorder • Rare/ controversial. • Apparent existence of two or more distinct personalities within an individual • Only one of them evident at a time. • One personality is usually dominant but neither has access to the other. • Switch from one to the other is sudden and closely associated with stressful event.

12. Factitious Disorders • Munchhausen’s syndrome/hospital hopper syndrome: • Individual feigns symptoms repeatedly and consistently. • Self-infliction of cuts or abrasions to produce bleeding, • The imitation may be so convincing- repeated investigations and operations are performed at several different hospitals. • The motivation is obscure- disorder of illness behaviour/sick role. • DD: Malingering- intentional production of symptoms , motivated by external incentives like evading criminal prosecution, obtain sickness benefits etc.

13. Conversion vs somatoform vs factitious vs malingering

14. Take home message • Dissociative, somatoform and factitious disorders present with vague somatic symptoms, often to the physicians. • Unnecessary and expensive investigations to be avoided. • Empathic approach helps. • Referral to psychiatrist/ consultation liaison with psychiatrist is important in managing these problems.

15. THANK YOU