Dissociative and Somatic Disorders

Somatic Disorders

• Somatic disorders relate to the body and involve physical experiences of psychological disorders, such as discomfort, stress, and conflict
• These disorders are commonly seen in primary care, estimated in 25% of patients
• Genetic, biological, early traumatic, and learned factors in family/society are causes of somatic disorders
• Strong association between domestic/sexual violence and somatic complaints

Somatic Disorders: Cultural Context

• Cultural and social norms can devalue and stigmatize psychological suffering compared to physical suffering
• Differences in medical care across cultures have an effect on the expressions of personal suffering inserted in a cultural and social context
• Western cultures often seek biomedical explanations
• Some cultures express distress through physical symptoms
• Cultural beliefs influence treatment choices

Somatic Disorders: Common Characteristics

• Symptoms usually last for 6 months or more, but can be less
• They cause distress or disruption of daily life
• There is no underlying medical condition or causes
• They are not related to medication/drugs/toxins
• Not better explained by another DSM diagnosis (e.g., schizophrenia)
• Requires thorough H and P, labs, imaging, neurologic tests for diagnosis
• Perform age-appropriate screening tests

Somatic Symptom Disorder (SSD) Criteria

• May occur alone or in conjunction with a medical illness
• Presentation with one or more physical complaints
• Pain: Headache, joint pain
• GI: Nausea, vomiting, diarrhea, bloating
• Pelvic symptoms: pain, fullness, dyspareunia
• Neurological symptoms: paresthesia, headaches
• Symptoms are moderate to severe
• One or more of the following
• Disproportionate thoughts about the seriousness
• Persistently high level of anxiety
• Excessive time and energy devoted to symptoms and concerns

SSD: Patient Characteristics

• Repeatedly checking one's body for abnormalities
• Avoiding physical activity
• Unusually high sensitivity to medication side effects
• Seeking care from multiple doctors for the same somatic symptom(s)
• Clinicians may find themselves feeling frustrated
• Patient may refuse to grant permission to speak with other clinicians

SSD: When to Suspect

• History is vague and inconsistent
• Patient concerns are rarely alleviated by thorough work up
• Reassurance and explanation provides only temporary relief and are interpreted that the clinician does not understand or take them seriously
• Multiple courses of standard treatment fail to mitigate symptoms

SSD History

• Check for triggers, such as social situations, relationship, work, and children
• Ask about previous early symptoms
• Inquire about stressful personal events or losses
• Identify any secondary gain, such as disability benefits, litigation
• Check for history of abuse and current safety issues
• Assess for suicide or homicide ideation
• Ask "What do you think is causing this?"
• Ask "How were your previous healthcare providers?
• Ask "Is there anything I can say to reassure you?"

SSD Work Up

• As in any psychiatric illness to rule out a physical cause
• Over-testing and serial testing should be avoided as opposed to missing a diagnosis
• False positive testing incites more cost, tests, anxiety, adverse outcomes
• The danger of diagnosing as somatic symptom disorder
• Difficult to assess, less common diagnosis, inconvenient and time-consuming
• Inform patient about testing and what it can rule out
• Neuropsychological testing can confirm the SSD diagnosis
• Minnesota Multi-personality Inventory (MMPI-2)
• The Symptom Checklist-90-R (SCL-90-R) - Should be addressed like any other test, matter-of-factly

SSD Sample Medical Differential Diagnosis

• Chronic physical pain syndromes
• Fibromyalgia
• Phantom limb pain: post amputation
• Osteoarthritis
• Complex regional pain syndrome
• Lyme disease
• Multiple sclerosis or neurodegenerative disease
• Always read the medical record completely, record your findings completely, and communicate fully with consultants

SSD Treatment Strategies

• "Cure sometimes, treat often, comfort always"

SSD Treatment

• Patients are disturbed being told there is "nothing wrong" after a workup
• State the reality that “the tests are normal, nothing abnormal/ concerning was found"
• Explain that "the body can generate symptoms in the absence of disease" and the limits of medical knowledge
• Acknowledge suffering and pain
• Schedule regular, brief (rather than symptom-based) appointments: "what would you like to have happen today?"
• Lengthy medical histories mean a long-term relationship with a trusted primary care practitioner is needed that prevents unnecessary treatments, increasing patient comfort
• Keep referrals to specialists to a minimum
• Monitor the patient for any new physical symptoms or diseases
• Work with a psychiatric consultant, especially for the clinician
• Introduce contextual factors as amplifiers rather than causes for the patient's symptoms
• Build an effective, blame-free narrative that links physical and psychosocial mechanisms, making sense to the patient
• Encourage and monitor behaviors such as positive thinking, relaxation techniques, graded exercise, and self-help guides
• Set realistic goals together with the patient
• Provide symptomatic measures such as pain relief or digestives; allow measures from complementary medicine according to the patient's wishes, explaining that these measures are temporarily helpful but less effective than self-management
• Consider antidepressant medication if there is predominant pain or depression
• Cognitive Behavioral Therapy
• Mindfulness meditation
• Group therapy or support groups are useful, particularly if their social network has been limited by their pain symptoms
• Distraction from symptoms with anything fun, enjoyable, or interesting
• Medications: Anti-anxiety or antidepressant medications if coexisting mood or anxiety disorder, Duloxetine, amitriptyline for chronic pain
• Hypnosis can recover memories and thoughts connected to the onset of symptoms
• Almost any organic cause of pain can be temporarily relieved by medication, rest, sleep, or positioning
• Use "I can not tell the difference (between a medical condition and SSD) and neither can you" to get buy-in for psychiatric and counseling services
• You can also offer "I can't tell where your pain is coming from. Would you be willing to explore this with (another) doctor?" for psychiatric/psychological referral
• Family therapy is recommended if the parents and or patient are using the child or themselves to divert attention from conflict
• It helps avoid reinforcing dependency within the family setting

Illness Anxiety Disorder (IAD)

• Formerly Hypochondriasis
• Unduly concerned or preoccupied with health but usually with no specific symptoms
• May be in traditional or non-traditional medical practices
• Learned vs genetic vs OCD variant
• Somatic symptoms are not present or mild while preoccupation is excessive.
• Excessive health-related behaviors and utilization of health care or avoid hospitals or doctors
• IAD Work Up: similar to SSD
• IAD Treatment: similar to SSD, reassure patients, work up and avoid excessive testing, psychotherapy, CBT specific for IAD, trial of SSRIs starting low to avoid side effects
• Illness Anxiety Disorder Prognosis: Chronic condition with mild to severe outcomes

Somatic Symptom Disorder and Illness Anxiety Disorder Compared

• Both diagnoses replaced Hypochondriasis in the DSM-5
• In both, there is a high level of anxiety about health
• The only difference between them is that one has actual health/physical symptoms accompanying the extreme worry, and the other one doesn't.
• Somatic symptom disorder (SSD) is characterized by somatic symptoms that are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings and behaviors regarding those symptoms
• To be diagnosed with SSD, the individual must be persistently symptomatic (typically at least for 6 months)
• Illness Anxiety Disorder is similar, with high health anxiety, but in this case, there are little to no somatic symptoms

Functional Neurologic Symptom Disorder

• Formerly Conversion Disorder
• Stressors manifest as neurologic symptoms with no organic causes that affect sensory or voluntary motor functioning
• Psychological trauma abuse/grief/accidents, Severe stress or anxiety, Subconscious coping mechanism brain blocking distress, Mental health conditions PTSD/Depression, Medical history and environment mimicking seen symptoms subconsciously are all possible causes
• Abnormal Movements may be present
• Astasia refers to the inability to stand upright unassisted
• Abasia refers to lack of motor coordination in walking
• Astasia-abasia is the inability to either stand nor walk in a coordinated manner
• Sample Symptoms are aphonia, dysphagia, weakness or paralysis, anesthesia, tremor, deafness, blindness, "attacks" or seizures with normal EEG, MRI, or incontinence of urine or bowel
• The deficit does not conform to known anatomical or physiological characteristics
• Glove anesthesia
• Neurological evaluation rules out physical causes

Functional Neurologic Symptom Disorder: Primary Gain

• Produces positive internal motivations
• For example, a patient might feel guilty about being unable to/afraid to perform some task
• The medical condition alleviates guilt and is unconscious and uncontrollable
• Can be a component of any disease, but most dramatically in conversion disorder, the mind inciting the body to produce real symptoms
• The "gain" may not be evident to an outside observer

Functional Neurologic Symptom Disorder Treatment

• Identify the disease and educate the patient as the condition is potentially reversible
• https://www.neurosymptoms.org/
• Physical Therapy with diverting attention, large to small movements
• Speech therapy, treat comorbid disease, and refer for psychotherapy/CBT
• Hypnosis, SSRIs (??)

Factitious Disorder

• The patient assumes the "sick" roll intentionally and feigns symptoms with rewards that are internal and unconscious
• Symptoms may be physical, psychological, or both
• Patients may injure themselves, insert objects under skin, rub feces or dirt in wound, catheters, or IVs, put blood in urine or other specimens, self-inject with blood thinners or insulin, or report sadness and depression due to loss of a spouse when never married.
• Management is to avoid angry confrontation, use psychological and psychiatric consultation, and CBT, while communicating the facts clearly and calmly
• Document findings and notify other clinicians
• Focus on life stressors
• Medications are not useful and room searches may cause ethical dilemma

Factitious Disorder Imposed on Another

• Formerly Munchhausen by proxy
• Patients intentionally produce symptoms in their child, aging family, or pets to maintain contact with medical providers
• Can result in serious injury or death
• Management involves child protective services and counseling for the caretaker and child

Malingering

• Intentionally pretending to have a mental or physical illness for conscious external secondary gain
• Examples are financial reasons, avoiding incarceration, unwanted duty, or other motivations

Physical Exam Tests for Malingering

• Arm drop test, Hoover test, and Waddell's signs are useful for assessing physical symptoms with no underlying organic cause

Arm Drop Test for Malingering

• Patient will avoid their face when their hand/arm is dropped

Hoovers Test

• The patient lies on her back
• The examiner places one hand under the heel of the "weak" leg and asks the patient to lift the strong leg against resistance
• If the patient is genuinely weak, the examiner should feel downward pressure from the "weak" leg due to involuntary muscle activation
• If no downward pressure is felt, it suggests the patient may not be exerting real effort, indicating possible malingering

Waddell's Signs: Regional

• Involves neighboring parts such as the leg below the knee, the entire leg, or a quarter or half of the body
• Not consistent with neuroanatomy
• Waddell's signs: Tenderness, Simulation, Distraction, Regional, Overreaction

Diagnosis Schema for Involuntary vs. Voluntary Symptoms

• It is important to decide if the production of symptoms is generally involuntary or voluntary in order to narrow the differential diagnosis

Somatic Symptom & Related Disorders: Key Features

• Somatic Symptom Disorder: Excessive anxiety & preoccupation with ≥1 unexplained symptoms
• Illness Anxiety Disorder: Fear of having a serious illness despite few or no symptoms & consistently negative evaluations
• Conversion Disorder: Neurologic symptom incompatible with any known neurologic disease; often acute onset associated with stress
• Factitious Disorder: Intentional falsification or inducement of symptoms with the goal to assume the sick role
• Malingering: Falsification or exaggeration of symptoms to obtain external incentives and secondary gain

Dissociative Disorders

• Everyday dissociation includes daydreaming, highway hypnosis, “auto pilot,” getting lost in a book or movie, zoning out from overstimulation, and meditation
• All can involve “losing touch” with awareness of one's immediate surroundings.
• Dissociative Disorders include Out of body experiences and Near Death Experiences
• They involve an interruption of awareness from fundamental aspects of waking consciousness. This effects memory (amnesia), surroundings (fugue), self (depersonalization), identity, emotion, and perception
• Affects life functioning and is long lasting
• Dissociative Events are Common with depression, anxiety, PTSD, trauma, or inner conflict.
• Protective mechanisms of altered consciousness due to overwhelming trauma or abuse, children/ adults with physical, sexual and emotional abuse/assault, unpredictable and frightening home environment, and increased stress
• Children more able to disassociate
• Impairs life functioning in work and relationships and is not better explained by another mental disorder

Ascending Severity of Dissociative Disorders

• Depersonalization/Derealization Disorder
• Dissociative Amnesia (with/without fugue)
• Dissociative Identity Disorder

Depersonalization Disorder

• Experience of feeling detached from themselves with a sense of experiencing from afar or as if a movie

Derealization Disorder

• Experience of surroundings as unreal with a feel of being outside or lacking control; "Numb”, “Foggy"

Depersonalization / Derealization Disorder

• Reality testing remains intact while episodic or continuous
• Common as high as 20-50% of population may experience a single episode
• Refer for psychotherapy/ CBT weekly, reassure patients this is not a psychotic disorder, use “Grounding” practices: breathing, awareness/exercise, hand rubbing, foot stomping, and conduct a Lamotrigine trial
• Use Transcranial magnetic stimulation (TMS), SSRIs are of no benefit, and consider https://www.livingwell.org.au/well-being/mental-health/grounding-exercises/

Dissociative Amnesia Diagnostic Criteria

• Inability to recall important personal information, usually of a traumatic or stressful nature, that can't be explained by forgetfulness/organic cognitive impairment
• Localized or selective amnesia for a specific event or events
• Patient may minimize the importance of memory loss, generalized amnesia for identity and life history, or semantic/procedural knowledge intact, but there is no reality testing impairment

Dissociative Amnesia

• Mental Status involves patients who are awake and alert but they may speak slowly and have minimal if any impairment in concentration
• It is caused by physical, sexual, or emotional abuse, natural disasters, war or combat, witnessing or experiencing a violent crime, or may be genetically predisposed

Dissociative Amnesia Differential

• Post-concussive syndrome, post ictal period after seizure, petit mal seizure, dementia, Korsakoff Syndrome (antegrade/ retrograde amnesia and confabulation from Thiamine deficiency), malingering, acute substance intoxication, and delirium

Dissociative Amnesia With Dissociative Fugue

• Suddenly and unexpectedly travel away from their home geographic location with impaired recall of their past
• May be confused about their former identity and assume a new identity
• Link this to https://www.youtube.com/watch?v=cjo2IQK6prs and http://www.youtube.com/watch?v=Q9_dqu7qz2w
• Read in The Guardian: https://apple.news/AZ7zdGgGLRxyeLusFdylMfQ

Dissociative Amnesia +/- Fugue Treatment

• Psychotherapy and gradually re-expose the person to facts/events from their established life to provide strong support
• Hospitalization may be necessary and hypnosis useful
• Medications are not useful

Dissociative Identity Disorder (DID)

• Formerly Multiple Personality Disorder
• Two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
• Can have personalities or "alters" that don't always know the other alters' information with a coordinating personality and recurrent gaps in the recall of everyday events, including important personal information and or traumatic events
• Children may present symptoms that are not attributable to imaginary playmates or other fantasy play.
• May be helpful to think of Dissociative identity disorder or DID Personalities or Alters as having distinct names, behaviors, memories, voices, and ways of viewing the world in addition to medical problems
• Alters may also have a different gender, ethnicity, age, or could be an animal that merge and switch for just brief moments or days.
• Alters may present with physical differences, such as allergies, diabetes right-or-left handedness or the need for eyeglass prescriptions
• Dissociative Experiences Scale II can be a useful aid in diagnosis, providing a patient survey of symptoms related to DID with 28 questions using a Likert scale

DID vs Schizophrenia

• Dissociative Identity Disorder (DID) involves an emotionally congruent, dramatic presentation while schizophrenics are flat or have inappropriate affect
• DID has a strong link to severe childhood trauma whereas schizophrenics have a genetic predisposition with no necessary trauma history
• DID features multiple identities while schizophrenics may have delusions, but no multiple identities
• High dissociation (memory gaps, identity shifts) are key symptoms in DID while hallucinations, delusions, and disorganized thinking are common in schizophrenia

DID Treatment

• Psychotherapy can assist patients in understanding the cause of their condition and form new ways of coping with stressful circumstances, integrating altered traumatic painful experiences
• Conduct integration of alters, which is usually of long duration in addition to assessment for suicide and unsafe behaviors Replication of unsafe relationships and experiences and achieve Get “alliance” from personality parts with Communication with parts or "shadow work."
• Neurofeedback, hypnosis and CBT are all useful