19. Conversion Disorder & Hypochondriasis.pptx
- 1. CONVERSION DISORDER AND HYPOCHONDRIASIS By Mohammed Abdi Assessor- Dr. Elizabeth
- 2. CONTENTS • Definition • Epidemiology • Comorbidities • Etiology • Diagnostic criteria's • Clinical features • Differential Diagnosis • Course and prognosis • Treatment
- 4. Definition • Is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors.
- 5. Cont.. • The SXs or deficits are not intentionally produced. • Not caused by substance use. • Not limited to pain or sexual sxs. • Gain is primarily psychological and not social, monetary, or legal.
- 6. Cont…. • referred to as hysteria, conversion reaction, or dissociative reaction. • The term conversion was introduced by Sigmund Freud, who, based on his work with Anna O, hypothesized that the symptoms of conversion disorder reflect unconscious conflicts.
- 7. Epidemiology • Some SXs, but not severe enough to warrant dX in 1/3 of general population at some time during their lives. • Range in general population of 11-300/100,000 • The ratio of F: M among adult pts is at least 2:1. • The onset is generally from late childhood to early adulthood and is rare before 10 yrs of age or after 35 yrs of age.. • When SXs suggest a CD onset in middle or old age, the probability of an occult neurological or other medical condition is high.
- 8. Cont.. • Symptoms in women more common on left side of body. • Women with conversion symptoms more likely to subsequently develop somatization disorder. • An association exists b/n conversion disorder and antisocial personality disorder in men. • Men with conversion disorder often involved in occupation or military accidents. • SXs in children younger than 10 yrs of age are usually limited to gait problems or seizures.
- 9. Cont…. • Most common among • Rural populations • Persons with little education • Those with low intelligence quotients, • Those in low socioeconomic groups, • Military personnel who have been exposed to combat situations. •An increased frequency • monozygotic, but not dizygotic, twin pairs. • Relatives of people with conversion disorder.
- 10. Comorbidities • Common Axis I psychiatric conditions: • Depressive disorders (increased suicide risk) • Anxiety disorders • Somatization disorders • Conversion in schizophrenia reported but considered uncommon, yet ¼ to ½ admissions to a psychiatric unit for conversion disorder have significant mood disorder or schizophrenia • Personality Disorders • 5 to 21% histrionic • 9 to 40% passive-dependent type • Antisocial • Medical and especially neurological disorders occur frequently, with elaboration of symptoms stemming from original organic lesion
- 11. Etiology • Multidimensional • Psychoanalytic Factors • Learning Theory • Biological Factors
- 12. Cont… Psychoanalytic Factors • repression of unconscious intrapsychic conflict and conversion of anxiety into a physical SX. • The conflict is b/n an instinctual impulse and the prohibitions against its expression.
- 13. Cont… • The SXs allow partial expression of the forbidden wish or urge but disguise it, so that pts can avoid consciously confronting their unacceptable impulses; that is, the conversion disorder SX has a symbolic r/n to the unconscious conflict. • SXs also allow pts to communicate that they need special consideration and special Rx. • Such SXs may function as a nonverbal means of controlling or manipulating others.
- 14. Cont…. Learning Theory • Conversion disorder considered as piece of classically conditioned learned behavior • Symptoms of illness, learned in childhood, are called forth as a means of coping with an otherwise impossible situation.
- 15. Cont.. Biological Factors • Brain-imaging studies found impaired hemispheric communication in the cause of conversion disorder. • Excessive cortical arousal that sets off negative feedback loops b/n the cerebral cortex and the brainstem reticular formation.
- 16. Cont.... • Elevated levels of corticofugal output, in turn, inhibit the pt's awareness of bodily sensation, which may explain the observed sensory deficits in some pts. • Neuropsychological tests reveal subtle cerebral impairments in verbal communication, memory, vigilance, affective incongruity, and attention in these pts.
- 17. Table 17-5 DSM-IV-TR Diagnostic Criteria for Conversion Disorder
- 19. Clinical Features • Paralysis, blindness, and mutism are the most common SXs. • Depressive and anxiety disorder SXs often accompany the SXs of conversion disorder, and affected pts are at risk for suicide.
- 20. Cont…. Sensory SXs • Anesthesia and paresthesia are common, especially of the extremities. • All sensory modalities can be involved, and the distribution of the disturbance is usually inconsistent with either central or peripheral neurological dz. • SXs may involve the organs of special sense and can produce deafness, blindness, and tunnel vision. • These SXs can be U/bilateral, but neurological evaluation reveals intact sensory pathways. • In CD blindness, for example, pts walk around without collisions or self-injury, their pupils react to light, and their cortical evoked potentials are normal.
- 21. Cont…. Motor symptoms • Abnormal movements (gait disturbance, weakness/paralysis) • Movements generally worsen with calling of attention • Possible gross rhythmical tremors, chorea, tics, and jerks • Astasia-abasia (wildly ataxic/staggering gait, gross irregular/jerky truncal movements, thrashing/waving of arms- rare falls w/o injury) • Paralysis/paresis involving one, two, or all four limbs (w/o conformation to neural pathways) • Reflexes remain normal • No fasciculations/muscle atrophy (except chronic conversion) • Normal electromyography
- 22. Cont… Seizure SXs • Pseudoseizures are another SX. • About 1/3 of the pt's pseudoseizures also have a coexisting epileptic disorder. • Tongue-biting, urinary incontinence, and injuries after falling can occur in pseudoseizures, although these SXs are generally not present. • Pupillary and gag reflexes are retained after pseudoseizure. • No postseizure increase in prolactin concentrations.
- 23. Cont.. Associated psychological symptoms • Primary gain • Secondary gain • La belle indifference • Identification
- 24. Cont.. Primary Gain • Pts achieve primary gain by keeping internal conflicts outside their awareness. • SXs have symbolic value; they represent an unconscious psychological conflict.
- 25. Cont… Secondary Gain • Pts accrue tangible advantages and benefits as a result of being sick; for example, being excused from obligations and difficult life situations, receiving support and assistance that might not otherwise be forthcoming, and controlling other persons' behavior.
- 26. Cont… La Belle Indifférence • Pt's inappropriately cavalier attitude toward serious symptoms; that is, the pt seems to be unconcerned about what appears to be a major impairment. • The presence or absence of la belle indifférence is not pathnognomonic of conversion disorder, but it is often associated with the condition.
- 27. Cont… Identification • Pts with conversion disorder may unconsciously model their symptoms on those of someone important to them. • For example, a parent or a person who has recently died may serve as a model for conversion disorder. • During pathological grief reaction, bereaved persons commonly have SXs of the deceased.
- 28. Differential Diagnosis • Medical disorders. • Anxiety, depressive and psychotic disorders. • Other somatoform disorders. • Malingering and factitious disorder.
- 29. Course and Prognosis • Acute onset, usually. • Symptoms or deficits are usually of short duration. • and approximately 95% of acute cases remit spontaneously, usually within 2 weeks in hospitalized patients. • Recurrence occurs in 1/5 to 1/4 of people within 1 year of the first episode.
- 30. Cont… • A good prognosis predictor • Acute onset • Presence of clearly identifiable stressors. • A short interval between onset and the institution of treatment. • Above average intelligence. • Paralysis, aphonia, and blindness . • preceded by good premorbid psychological health. • Absence of comorbid neurologic or psychiatric disorders.
- 31. Cont……. • Poor prognostic factors • If symptoms have been present for 6 months or longer. • Tremor and seizures .
- 32. Treatment • Multimodal and varies according to the acuteness of the SX. • If the SX is acute, SX relief often occurs spontaneously or with suggestive techniques. • If the SX is chronic, it is often being reinforced by factors in the pt's environment; therefore, behavioral modification techniques are necessary. Psychopharmacologic Interventions • No specific psychopharmacologic interventions for conversion disorder. • However, when comorbid conditions are identified (e. g., depression), these conditions must be treated with the appropriate medications.
- 33. Cont… Psychotherapeutic Interventions • Acute conversion SXs may, on occasion, respond to insight-oriented psychotherapy techniques. • On the whole, insight-oriented therapies have not been effective for chronic conversion symptoms, which generally require behavioral modification for symptom relief.
- 34. Cont…. Other Interventions • Hypnosis and Amobarbital Interviews: An acute conversion SX may remit with suggestions through hypnosis or by the use of an Amytal (or lorazepam) interview that creates an altered state of consciousness.
- 35. Hypochondriasis
- 36. Introduction • The term hypochondriasis is derived from the old medical term hypochondrium, (below the ribs) and reflects the common abdominal complaints of many pts with the disorder, but they may occur in any part of the body. • It was thought by many Greek physicians of antiquity that many ailments were caused by the movement of the spleen. • Later in 19th Century used term to mean, “illness without a specific cause.” • The term evolved to be the male counterpart to female hysteria. • In modern usage, the term hypochondriac is often used as individuals who hold the belief that they have a serious illness despite repeated reassurance from physicians that they are perfectly healthy.
- 37. Definition • Is the preoccupation with the fear of having a serious disease which persists despite negative investigations. • Characterized by 6 months or more of a general and nondelusional preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
- 38. Cont… • This preoccupation causes significant distress and impairment in one's life; • It is not accounted for by another psychiatric or medical disorder; • And a subset of individuals with hypochondriasis has poor insight about the presence of this disorder.
- 39. Epidemiology • 6-month prevalence of 4 to 6 % in a general medical clinic population, but it may be as high as 15%. • Men and women are equally affected. • Most commonly appears in persons 20 to 30 yrs of age. • Social position, education level, and marital status do not appear to affect the dX. • about 3 % of medical students, usually in the first 2 yrs, but they are generally transient.
- 40. Etiology • Persons with hypochondriasis augment and amplify their somatic sensations. • They have low thresholds for, and low tolerance of, physical discomfort. • They may focus on bodily sensations, misinterpret them, and become alarmed by them b/c of a faulty cognitive scheme.
- 41. Cont…. • The SXs are viewed as a request for admission to the sick role made by a person facing seemingly insurmountable and insolvable problems. • The sick role offers an escape that allows a pt to avoid noxious obligations, to postpone unwelcome challenges, and to be excused from usual duties and obligations.
- 42. Cont…. • hypochondriasis is a variant form of other mental disorders, among which depressive disorders and anxiety disorders are most frequently included. • An estimated 80% of pts with hypochondriasis may have coexisting depressive or anxiety disorders. • Pts who meet the diagnostic criteria for hypochondriasis may be somatizing subtypes of these other disorders.
- 43. Cont…. • Aggressive and hostile wishes toward others are transferred (through repression and displacement) into physical complaints. • The anger originates in past disappointments, rejections, and losses, but the pts express their anger in the present by soliciting the help and concern of other persons and then rejecting them as ineffective. • Also viewed as a defense against guilt, a sense of innate badness, an expression of low self-esteem, and a sign of excessive self-concern. • Pain and somatic suffering, thus, become means of atonement and can be experienced as deserved punishment for past wrongdoing (either real or imaginary) and for a person's sense of wickedness and sinfulness.
- 44. DSM-IV-TR Diagnostic Criteria for Hypochondriasis
- 45. Clinical Features • Pts believe that they have a serious disease that has not yet been detected, and they cannot be persuaded to the contrary. • They may maintain a belief that they have a particular dz or, as time progresses, they may transfer their belief to another dz. • Their convictions persist despite negative laboratory results, and appropriate reassurances from physicians. • Their beliefs are not sufficiently fixed to be delusions. • Often accompanied by SXs of depression and anxiety and commonly coexists with a depressive or anxiety disorder.
- 46. Cont…. • Transient hypochondriacal states can occur after major stresses, most commonly the death or serious illness of someone important to the pt, or a serious illness that has been resolved but that leaves the pt temporarily hypochondriacal in its wake. • Such states that last < 6 months should be dxsed as somatoform disorder not otherwise specified. • Transient hypochondriacal responses to external stress generally remit when the stress is resolved, but they can become chronic if reinforced by persons in the pt's social system or by health professionals.
- 47. Differential Diagnosis • Medical conditions, especially disorders that show symptoms that are not necessarily easily diagnosed. • somatization disorder • Other somatoform disorders. • Depressive and anxiety disorders. • Psychotic disorders. • Factitious disorder and malingering.
- 48. Course and Prognosis • Usually episodic; the episodes last from months to years and are separated by equally long quiescent periods. • There may be an obvious association b/n exacerbations of hypochondriacal symptoms and psychosocial stressors. • 1/3 to 1/2 of all patients eventually improve significantly. • Most children with hypochondriasis recover by late adolescence or early adulthood.
- 49. Cont…. • A good prognosis is associated with High socioeconomic status. Treatment-responsive anxiety or depression. Sudden onset of symptoms. The absence of a personality disorder. The absence of a related nonpsychiatric medical condition.
- 50. Treatment • Pts usually resist psychiatric treatment. • Group psychotherapy often benefits such pts, in part b/c it provides the social support and social interaction that reduce their anxiety. • Other forms of psychotherapy, such as individual insight-oriented psychotherapy, behavior therapy, cognitive therapy, and hypnosis may be useful.
- 51. Cont… • Frequent, regularly scheduled physical examinations help to reassure pts. • Invasive diagnostic and therapeutic procedures should only be undertaken, however, when objective evidence calls for them. • Pharmacotherapy • Underlying anxiety disorder or major depressive disorder. • When hypochondriasis is secondary to another primary mental disorder
- 52. References • kaplan& sadock’s synopsis of psychiatry: behavioral sciences/ clinical psychiatry, 10th ed • Current diagnosis and treatment in psychiatry
- 53. Thank you