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Somatoform Disorders

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q Physical symptoms which represent CONVERSION of anxiety / emotional conflict ... Physiotherapy for the paralyzed limbs without losing face. Placebo medication. ... – PowerPoint PPT presentation

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Title: Somatoform Disorders


1
Somatoform Disorders 1.    Conversion
Disorder Hysterical Disorder q  Physical
symptoms which represent CONVERSION of anxiety /
emotional conflict INTO physical symptom
unconsciously.q Children lt adults.q Has
symbolic significance 1º gain
When symptoms serve to keep internal conflict/
need out of awareness. e.g. hand is
paralyzed after father had beaten him. 2º
gain A way of avoiding unwanted/
unpleasant/ anxious provoking situations.
e.g. inability to speak in the viva !q Common
symptomsBlindness paralysis aphonia
anesthesia of part of body.Child show no concern
about symptoms despite disability (la belle
indifférence).
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2
  • 2.    Epidemic hysteria
  • q CFx dizziness faintness headaches etc.
  • q Start in one child ? other children.
  • q Prevention of spread Isolate affected children
    strong suggestions to rest of them.
  • 3.    Dissociative disorders
  • q  Uncommon in childhood.
  • q  Characteristics
  • Subject is unaware of underlying problem, and is
    NOT malingering.
  • Changes in identity motor behavior.
  • q Dx by excluding physical disease / other
    psychological disorders which explain symptoms.
  • a)  Psychogenic amnesia
  • memory loss (for particular events/ people)
    during some period of time.
  • b)  Psychogenic fugue assuming new identity
    wandering away.
  • c)  Multiple personality disorder 2
    personalities at different times.
  • d)  Depersonalization disorder feelings of
    altered perception of self.

3
Mxq Assessment Hx, P/E ? may reveal
inconsistencies between S/S ? rule out physical
disease. MSE ? psychiatric disorders (esp.
emotional diso, depression).q Should be treated
as early as possible ? delay may allow symptoms
to become enriched fixed.q  On
out-patient basis, but if family maintains the
problem ? admission.q  ? Any stressful
events.q  Individual psychotherapy ? encouraging
child to talk about problems.q  Family sessions
to explain Absence of physical diseases.
In some children, emotional distress ?
physical symptoms!q  Behavioral therapy ve
reinforcement ? to encourage desirable
behaviors, while ignoring the symptoms.q  Face
saving solution e.g. Physiotherapy for the
paralyzed limbs without losing face. Placebo
medication.q  Hypnosis effective in highly
suggestive children.
4
4.  Hypochondriasisq  Rare in childhood, but
common in adolescence.q  They exhibit
exaggerated physical symptoms. Abdominal
pain (commonest), headache, nausea .etc.q  A/w
anxiety or depressive symptoms.q  Mx help
child deal with stress that produces
symptoms develop alternate coping strategies.
Parents should focus on adaptive behavior
rather than symptom behavior. 5.  Abnormal
illness behaviorq  Child is enjoying benefits
of sick role.q  ? ? in childhood. In
adolescence gt ?.
5
Depressive Disorders
  • q Depressive symptoms (sad mood, misery,
    tearfulness) occur in 20-25 of children
    adolescents, but are part of emotional or conduct
    disorders.
  • q Suicidal thoughts attempts are common in
    1/3 of adolescents (DSH is rare).
  • q Clinical syndrome of depression
  • 15-20 of children adolescents attending
    psychiatry clinic.
  • CFx
  • Persistent low mood (dysphoria).
  • Anhedonia.
  • depressive cognition (hopelessness,
    worthlessness, self-deprecation, guilt).
  •  
  •  q  Diagnostic criteria
  • 1. Persistent low mood (dysphoria) ?
    misery, sadness, tearfulness.
  • 2. A/w irritability,
    hypochondriasis, impaired concentration, social
    refusal, anxiety, OCD, running away from home,
    separation anxiety (school refusal, abd. pain,
    decline in school work, acting out behavior).
    Vegetative symptoms (sleep / appetite
    disturbance) gt in adolescents.
  • 3. Symptoms lasted for gt 4 weeks.
  • 4. Impairment of functioning.

6
q  Etiology multifactorial. Risks factors
are1.  Genetic predisposition.2.  Temperament
anxious sensitive children who are slow to
warm up and adapt to
new experiences ? predisposed to emotional
diso.3.  Traumatic experiences in early
childhood e.g. maternal deprivation, separation
from attachment figure.4.  Chronic life
adversity adverse family circumstances,
neglected/ abused children.5.  Individual
factors poor self-esteem due to perceived lack
of competence in school.6.  Life
events Bereavement ? N. emotional response
(depressive symptoms).7.  Social learning
development of self-esteem might be impaired by
experiences of
being in pain/ unpleasant situations over which
they have no control.8.  Depression may 2º to
other disorders Viral febrile illnesses e.g.
infectious mononucleosis. Psychiatric diso
conduct diso, adjustment diso, separation
anxiety, OCD etc.
7
Mxq  Depends on severity extent to which
symptoms impair functioning.q  If suicidal
intent ? admit the child !q  Identified stressed
should be alleviated.q  Mild-moderate reactive
cases of depression may be treated by out-patient
counseling, environmental manipulation,
individual psychotherapy, family therapy.
Cognitive therapy to enhance childs
self-esteem confidence.q  Moderate-severe
cases ? anti-depressants e.g. imipramine
amitriptytline, SSRI. OutcomeMost children
respond to intervention grow up to be normal
adults. However, if he/she develop psychiatric
illness later, its more likely to be depression.
8
Suicide parasuicide(Deliberate self-harm DSH)
  • q  Definitions
  • q  Completed suicide are not known to before the
    age of 10.
  • q  Threats of suicide attempts are not uncommon
    in children.
  • o   Incidence of DSH is highest in the age group
    15-19.
  • o   Suicide gt ?, Parasuicides gt ? and the
    common method is OD.
  •  
  • q  Assessment of suicidal intent
  • 1.  Planned attempt.
  • 2.  Measures to avoid discovery.
  • 3.  Final act (leaving a note, calling a friend).
  • 4.  Making sure that nobody is near the scene.
  • 5.  Use of violent / dangerous method.

9
q Risk factors1.  Child factors academic
difficulties, school refusal, relationship
problems, anti-social behavior, substance abuse,
physical / psychiatric illness, sexual
difficulties (sexual abuse, homosexuality,
pregnancy).2.  Family factors loss of parents,
mental illness (depression, suicidal behavior),
substance abuse, extremes of parental control
etc.3.  Environmental factors access to means
of suicide, suicidality in close friend,
precipitating factors e.g. hearing bad news
(school failure, death of someone close),
arguments with someone close. gt common on
special occasions e.g. Christmas, death
anniversary.
10
Mxq  All suicide attempts should be taken
SERIOUSLY as a communication of desperation
limited problem solving skills.q  Children who
committed suicide ½ would have talked about,
threatened / attempted suicide. ¼ would have
consulted their GP in previous week. ¼ had
anti-social behavior.q  All children should be
admitted following OD.q  Assessment of social
psychological factors should be carried out with
neutral non-judgmental attitude.q  Information
should be obtained from family, school, relevant
resources.What might appear trivial to others
may have deep personal significance for the
patient.
11
Cont Mxq  20 of cases show NO psychiatric
illnesses. Main aim of Rx is to enable patient
to resolve difficulties led to incident, and for
any future crisis without self harm.q  60 of
cases show evidence of psychiatric
illness.q  20 of cases, theres moderate-severe
psychiatric disturbance. Depression conduct
diso. are the commonest conditions a/w DSH.
Substance abuse is imp. risk factor
suicide. OutcomeFor most of children
adolescents ? outcome is GOOD. Minority continue
to have social psychiatric problems. 10-15
repeat during the course of one year, and 4-5
eventually kill themselves ?.
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