Dissociative, Somatoform, and Facticious disorders

Question 1

4 types of dissociative disorders
Which one is the most common?
Which one has the worst prognosis?

Answer 1

Dissociative

• Fugue
• Amnesia most common
• Identity disorder *worst prognosis)
• NOS

Question 2

DSM for dissociative amnesia?

Answer 2

at least 1 episode of inability to recall personal identity information, but able to remember obscure details

patients report gap(s) in the recollection of a particular event

usually precipitated by a traumatic/stressful event

Question 3

How to get patients with dissociative amnesia to try to remember things?

Answer 3

conduct interviews under hypnosis or Na-amobarbital or lorazepam - may help patients talk more freely

Question 4

Patients with dissociative amnesia are highly comorbid with: 2

Answer 4

MDD and anxiety disorders

Question 5

Prognosis of patients with dissociative amnesia?

Answer 5

good - many return to normal after minutes-days

Question 6

diagnosis and treatment for dissociative amnesia?

Answer 6

conduct interviews under hypnosis or Na-amobarbital or lorazepam - may help patients talk more freely

psychotherapy; ø specific Rx is approved for amnesia

Question 7

DSM for dissociative fugue?

how do these patients usually present?

Answer 7

• sudden, unexpected travel away from home + inability to recall one’s identity or past (may assume a new identity)
• pts are confused about new identity

pts are unaware of their amnesia/new identity; does not recall the period of the fugue; low anxiety despite their confusion

Question 8

DDx of dissociative fugue?

Answer 8

dissociative amnesia
dissociative identity disorder
dementia
delirium
complex partial seizure 
bipolar d/o
intoxication
malingering

Question 9

dissociative fugue treatment?

Answer 9

psychotherapy; ø specific Rx is approved for amnesia

Question 10

What is dissociative identity disorder?

Answer 10

multiple personality disorder

Question 11

DSM for dissociative identity disorder?

Answer 11

≥ 2 distinct personalities that take control of the person’s behavior; inability to recall personal personal information of one personality when the other is dominant

Question 12

What are some of the social factors surrounding dissociative identity disorder?

When is this usually brought on? When is it usually diagnosed?

Answer 12

Usually F with prior history of trauma, esp. childhood physical or sexual abuse

Avg age of onset: 6
Avg age of diagnosis: 30

Question 13

dissociative identity disorder is highly comorbid wtih:

Answer 13

MDD
anxiety
borderline personality disorder
substance abuse
suicide

Question 14

How is dissociative identity disorder diagnosed and treated?

Answer 14

conduct interviews under hypnosis or Na-amobarbital or lorazepam - may help patients talk more freely

insight-oriented psychotherapy

Question 15

What is depersonalization disorder (under DSM guidelines)

What is usually the precipitating factor?

Answer 15

persistent/recurrent feelings of detachment from one’s body, mental processes, or social situation; reality testing is intact!

STRESS

Question 16

Depersonalization disorder is highly comorbid wtih

Answer 16

MDD

anxiety disorders

Question 17

Treatment of depersonalization disorder?

Answer 17

anxiolytic or SSRI to treat associated sx of anxiety or MDD

Question 18

What are the types of somatoform disorders? 7

Answer 18

somatization
conversion
hypochondriasis
pain disorder
body dysmorphic disorder
undifferentiated somatoform disorder
somatoform disorder NOS

Question 19

How do patients with somatoform disorders present

Answer 19

enduring physical symptoms without an identifiable organic cause, which causes significant distress or impairment in social, occupational, or other area of functioning

TRULY BELIEVE that their symptoms are due to a medical problem; ie they are NOT consciously feigning symptoms

Question 20

∆ btwn 1˚ gain and 2˚ gain

Answer 20

1˚ = unconscious defense against unacceptable internal conflicts

2˚ = unconscious external benefits (increased attention, decreased responsibility, avoidance of the law)

Question 21

DSM for somatoform disorder

Answer 21

onset BEFORE 30
4 pain sx
2 GI sx
1 sexual/reproductive sx
1 pseudoneurological sx (localized weakness, sensation loss, tingling)

Question 22

social history of a patient with somatoform disorder?

Answer 22

hx of sexual and/or physical abuse

Question 23

treatment for patients with somatoform disorder?

Answer 23

regular scheduled visits with a single PCP who limits (but does not eliminate) medical workups in case there is an organic cause to the pain

address psychological issues - teach them how to be aware and express their emotions directly instead of developing physical sx

Question 24

DSM for conversion disorder

Answer 24

≥ 1 neurological (sensory or motor) symptom that is not explained by a medical condition or intentionally feigned or produced, such as

• shifting paralysis
• blindness
• mutism
• paresthesias
• seizures
• globus hystericus (sensation of lump in throat)

patients are pretty calm and unconcerned (la bell indifference) when describing their symptoms

Question 25

Ddx of conversion disorder? 5

Answer 25

``` Psomatization d/o undifferentiated somatoform d/o hypochondriasis facticious d/o malingering ```

Question 26

Prognosis of conversion disorder?

Answer 26

sx may be brief or last for several weeks or longer; high recurrence rate

Question 27

diagnosis and treatment of conversion disorder?

Answer 27

conduct interviews under hypnosis or Na-amobarbital or lorazepam - may help patients talk more freely insight-oriented psychotherapy

Question 28

What is hypochondriasis?

Answer 28

aka illness anxiety disorder these patients have - excessive behaviors (frequent checking body for illness, seeking reassurance from google), OR - exhibit maladaptive avoidance (avoiding people who are mildly sick or refusing to travel far from their PCPs) because they are preoccupied with fear of having/contracting a serious disease based on misinterpreting bodily symptoms despite medical evaluation and reassurance

Question 29

DSM for hypchondriasis?

Answer 29

≥ 6 months of preoccupation with fear of having/contracting a serious disease based on misinterpreting bodily symptoms despite medical evaluation and reassurance; leads to significant impairment in functioning

Question 30

hypochondriasis is usually comorbid with?

Answer 30

anxiety and depression, duh

Question 31

treatment for hypochondriasis?

Answer 31

regular scheduled visits with a single PCP CBT SSRI for treatment of anxiety and depression

Question 32

prognosis?

Answer 32

waxes and wanes; worsens under stress

Question 33

What is body dysmorphic disorder?

Answer 33

- patients who are preoccupied with the body parts that they perceive as flawed or defective and have strong beliefs that they are unattractive or repulsive - very self-conscious - spend significant amount of time trying to correct the perceived flaws with makeup, procedures, or surgery

Question 34

DSM for body dysmorphic disorder?

Answer 34

preoccupation with an imagined defect in appearance or excessive concern about a slight physical anomaly

Question 35

body dysmorphic disorder is highly comorbid with:

Answer 35

depression anxiety psychotic disorders*

Question 36

Who does body dysmorphic disorder usually happen in?

Answer 36

unmarried women btwn 15-20

Question 37

Treatment of body dysmorphic disorder?

Answer 37

SSRIs

Question 38

What characterizes pain disorder?

Answer 38

prolonged, severe discomfort without an adequate medical explanation (symptoms that are far in excess of the disease pathology)

Question 39

DSM for pain disorder? is it intentionally produced?

Answer 39

pain that is either > 1 anatomic site (without radiation), OR of sufficient severity to warrant clinical attention not intentionally produced!

Question 40

∆ btwn acute and chronic pain?

Answer 40

acute 6 mo

Question 41

who is likely to suffer from pain disorder?

Answer 41

F, 30-50s | increased incidence in 1˚ relatives, blue-collar workers

Question 42

pain disorder is highly comorbid with:

Answer 42

major depression anxiety disorder substance abuse (to treat pain)

Question 43

Treatment of pain disorder? What would you not treat them with?

Answer 43

SSRI psychotherapy, biofeedback, hypnosis NOT analgesics or narcotics because patients tend to become dependent on them

Question 44

What is biofeedback therapy?

Answer 44

relaxation technique in which patients are trained to induce physiological ∆s that results in a relaxation response: - alpha-waves on EEG - vasodilation of peripheral capillaries

Question 45

What is factitious disorder? is this intentional or non-intentional? is this considered to be 1˚ or 2˚ gain?

Answer 45

INTENTIONAL/CONSCIOUS production of medical or psychological symptoms in order to assume the role of a sick patient aka PRIMARY gain (as there are no external incentives) - these patients tend to look for some kind of emotional gain, such as sympathy from others

Question 46

Munchhausen syndrome is what type of disorder?

Answer 46

factitious disorder

Question 47

factitious disorder is usually present in this patient population

Answer 47

hospital/health care workers; associated with higher intelligence, poor sense of identity, poor sexual adjustment many with a history of child-abuse or neglect

Question 48

factitious disorder is highly comorbid with:

Answer 48

borderline personality disorder

Question 49

Malingering is coded on which Axis?

Answer 49

Axis I

Question 50

What is malingering? is this intentional or non-intentional? is this considered to be 1˚ or 2˚ gain?

Answer 50

INTENTIONAL/CONSCIOUS feigning of physical or psychological symptoms in order to achieve a personal gain or external reward ($$, drugs) SECONDARY gain

Question 51

How do patients with usually present?

Answer 51

multiple vague complaints that do not conform to a known medical condition; often uncooperative and refuse to accept a good prognosis even after extensive medical evaluation