Somatoform Disorders, Neurasthenia, Factitious Disorders and Dissociative Disorders

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  • Somatization disorder
    • Usually begins before the age of 30 years
    • May continue for years
    • Symptom pattern consists of a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms
  • Schizophrenia or related disorders, mood disorders and panic disorders are used as exclusion criteria for somatoform disorder.
  • Classical clinical vignette on Somatization disorder
    • Pankul, 46-year-old married lady presented with headache, sudden onset palpitations, epigastric discomfort with pain in left loin. Sometimes she also felt pain and tingling numbness in right upper limb. On enquiry, she also gave history of bad taste in mouth and nausea. Symptoms are present for the last 4 years and she has consulted many doctors of various specialities during this time. She refuses to accept that there is no adequate physical cause for the physical symptoms and accuses doctor of their incapability to diagnose her illness. She is suffering from Somatization disorder
  • Somatization disorder
    • It presents as multiple somatic complaints presented in dramatic manner and involving multiple organ system.
    • The symptoms are recurrent and chronic and should be present for more than 2 years for making a diagnosis.
    • Patients visit several physicians but there is persistent refusal to accept advice or re-assurance of all of them.
  • Classical clinical vignette on Hypochondriasis
    • Sowmya, 43-year-old married female presented with complaints of headache for the last 6 months. She has had various consultations, including of Neurologist. All her investigations were found to be within normal limits. She still insists that there is something wrong in her head, probably a brain tumour and seeks another consultation. The most likely diagnosis in this case would be Hypochondriasis
  • A belief of having a serious disease, resulting from inaccurate interpretations of physical symptoms by patient, even though no known medical cause can be found, which results in significant distress to patients and also impairs their personal, social and

occupational roles is known as         Hypochondriasis

  • Hypochondriasis
  • It is a type of somatoform disorder.
  • It is a persistent pre-occupation with fear or belief of having serious disease(s), based on person’s own interpretation of normal body functions or minor physical abnormality.
  • This belief persists in spite of normal laboratory reports.
  • A disorder characterized by the presence of one or more neurological symptoms, e.g., paralysis,blindness, but cannot be explained by a known neurological or medical disorder, not intentionally produced but precipitated by conflicts or other

stressors, is known as Conversion disorder

  • Classical clinical vignette on Neurasthenia
    • Somaiah, 53-year-old bank employee complained of increasing fatigue for the last 4 years. He gets totally exhausted after 1-2 hours of work. Somehow he is able to manage his job because of considerate boss. When he returns home in the evening, he feels like going straight to bed. But then he had difficulty sleeping because of headaches and pains in his neck and back. Also throughout day, he feels tense and unable to relax. He also has become irritable because of this. Most probable diagnosis in this case will be Neurasthenia
  • Intentional feigning of physical or psychological signs or symptoms to assume sick role but without any external incentive for the behaviour is characteristic of Factitious disorder
  • Somatization disorder is characterized by the extreme course of multiple hospitalizations, and willingness to undergo repeated investigations.
  • Personality disorder people usually do not volunteer

for invasive procedures, or resort to a way of life marked

by repeated or long term hospitalization.

  • Malingerer’s have an obvious, recognizable environ

mental goal in producing signs and symptoms.

  • Dissociation is present in
    • Fugue
    • Somnambulism
    • Delirium
  • Dissociative phenomenon is exemplified by Trance and Possession disorder
  • Most common dissociative symptom is Sleep walking
  • Pseudocyesis
    • A false pregnancy
    • A conversion hysteria
    • May occur in males
  • Hysteria.
  • A neurosis with symptoms based on conversion, characterized by lack of control over acts and emotions; by morbid self consciousness, by anxiety, by exaggeration of the effect of sensory impressions and by simulation of various disorders.
  • The condition occurs in the absence of organic disease to account for the symptoms.
  • It occurs in both sexes before and after adolescence, and during periods of emotional and physical stress.
  • Conversion type Hysteria is manifested as sudden involuntary psychogenic loss of function of special senses or the voluntary nervous system in response to stress.
  • Dissociate type Hysteria is manifested by alterations of state of consciousness or of identity.
    • Hysteria in a bank manager will respond best to Psychoanalysis
    • A condition in which a patient has nearly all of the usual signs and symptoms of pregnancy, such as enlargement of abdomen, weight gain, cessation of menses, and morning sickness, but is not pregnant.
    • Usually seen in women who either are very desirous of having children or wish to avoid pregnancy.
    • Treatment usually is done by psychiatric means.
    • Pseudocyesis may also be seen in men.
    • Synonym: Phantom Pregnancy; Pseudopregnancy
  • Fugue (L. fuga, flight).
    • A dissociative disorder in which the person acts in a normal manner but has almost complete amnesia for what happened when recovery occurs.
    • “Fugue” state may be seen in:
      • Alcohol intoxication
      • Epilepsy – Temporal Lobe
      • Schizophrenia
    • Fugue, psychogenic.
      • Sudden unexpected travel away from one’s home or place of work with inability to recall one’s past.
      • The individual may partially or completely assume a new identity.
      • The condition is not due to organic brain disease.
      • The condition may follow severe mental stress such as marital quarrels or a natural disaster.
      • It is usually of short duration but can last for months.
      • Recovery is the usual outcome without recurrences.
    • “La belle indifference” (Fr. Beautiful indifference)
    • seen in Dissociative disorders
    • An unrealistic degree of indifference to, or complacency about, startling and gross symptoms of hysterical anaesthesia or paralysis, seen in conversion reaction.
  • Characteristic features of “Dissociative disorder”,
    • Sudden onset and recovery
    • Precipitated by stress or secondary gain
    • Disturbance of consciousness and memory
  • According to definition of dissociative disorder by DSM-

IV, the amnesia in dissociative disorders is too extensive and persistent to be explained by ordinary forgetfulness (although its depth and extent may vary from one assessment to the next), or by intentional simulation.

  • Characteristic features of “Trance” state,
    • Loss of usual sense of personal identity
    • Unusually narrow and selective focusing on environmental stimuli
    • Limitation of movements, postures, and speech to repetition of a small repertoire
  • The conviction that individual has been taken over by a spirit, power, deity, or other person, is characteristic of possession disorder.
  • Multiple personality disorder
    • Existence of two or more personality states in an individual, alternatively and recurrently taking control of person’s behavior
    • Transition from one personality to another is often

sudden and dramatic with amnesia of previousstates

Individuals may complain of hearing voices originating from within

  • The diagnostic criteria for multiple personality disorder

states that disturbances should not be due to the direct physiological effects of a substance (e.g. blackouts orchaotic behaviours during alcohol intoxication) or a general medical condition (e.g. complex partial seizures).

  • “Ganser’s Syndrome”,
    • Voluntary production of severe psychiatric symptoms with giving of approximate answers
    • Commonly associated with dissociative phenomena
    • Characterized by pansymptomatic nature of illness with worsening of symptoms when patients believe that they are being watched
    • People with syndrome respond to simple questions by giving near to correct answers, i.e. approximate answers., i.e. 2 plus 2 equals 5 etc.
    • Recovery is sudden and complete.
    • The psychological symptoms generally represent patient’s sense of mental illness.
    • Ganser’s syndrome is apparently most common in men and in prisoners.
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