15 Abuse and somatoform disorders Flashcards
IPV dynamics
- 6X per year events with lulls in between- this might contribute to denial/staying
- Protecting partner to “not turn on family”
- Isolation
- changing standards
IPV
Assultive behavior to dominate, control, or punish an intimate, supposedly peer, relationship.
- Phsyical 39% lifetime incidence 25% lifetime incidence of injury
- Sexual 22% females forced to do something sexual (9% of those spouse, 46% someone they love)
- Pet/property destruction
- psychological battering/terrorism
Women are attacked more often by current former partner, men assaults are more non-IPV
Bisexuals have higher rates of IPV
Societal dynamics
Woman may not have means to survive on own
Woman may be denied help if husband is wealthy
IPV and injuries
Facial injuries more commonly IPV More healthcare visit vs. controls. *trauma *surgical disorders *gynecologic *induced abortion *Med disorder *obs.
More suicide attempts and psych visits
IPV cost
$439 per year per patient; 19.3 M yearly
8.1 billion impact including lost work etc.
IPV and kids
80-90% in assaultive homes witnessed assault
Adult problems are associated with adverse childhood events in a dose dependent manner
Abuse and health
- Lead to impaired symptom reporting, worse med adherence (might not have even heard you), and inability to cope (resulting in bad coping strategies like alcohol etc.)
- Constant stress changes endocrine axis
- sleep disruption
Barriers to diagnosing and treating IPV
Patient:
- Lack of trust
- Safety jeopardized
- Financial support jeopardized
- shame and humiliation
- futile resignation
Provider:
- lack of knowledge
- lack of skills and training
- fear of offending patient
- too close for comfort (personal experience)
- Opening pandora’s box
IPV screen
- In my practice I’m concerned about prevention and safety, especally in the family
- Have you been hit, kicked, punched or otherwise hurt by someone in the last year? If so, by whom?
- Do you feel safe in your current relationship
- Is there a previous partner who is making you feel unsafe now?
IPV screen in family/relationship history
When did you and your partner meet?
What was the attraction?
What happens when you argue or fight?
Has your partner ever pushed, kicked, or grabbed you?
Good Interview skills
- Ask specific behaviors
- Avoid general emotionally charged terms like abuse, violence, and victim
- Ask about various types of violence and responses: fear, injury, sexual assault, control
- Ask about current problems from PREVIOUS RELATIONSHIPS
Helping IPV patients
SOS DOC
*support, belief, confidentiality
*safety: help assess danger- increasing frequency, weapons, substance
*options: safety planning and follow up- shelters, police, advocacy
*strengths - identify patient strengths- courage, care for kids etc.
*document- use qotes- not “claimed or alleged”
*Observations- detailed observations and pics with face and ruler (humanity and scale
- Assessment “consistent or inconsistent with MOI” include
perpetrator name
*Continuity- encourage follow up, connect to resources
IPV pitfalls
- not asking when you have the chance
- trivializing the violence
- overreacting to violence or denial
- simply recommending “getting out”
Sexual violence
- non-consensual
- Force or coercion
- sexual in nature
LESS THAN 35% is reported
1in3 girls, 1in6 boys by 18
Rape definition
Any penetration of anus or vagina, or penetration of mouth with sex organ without consent.
Non stranger sexual iolence
- Betrays trust and may change victims perception of world and trust
- Uses deceit, manipulation and secrecy
Trauma reactions
- Control is lost—>
- attempt to regain control and personal safetty
- perception or belief that one is unable to defend or care for oneself –>
- One reasserts control by using coping stratigies and problem solving skills based in previous practice.
Psychological trauma
- Decreased hippocampal and amygdalar volume
- alters cortisol and neurotransmitters
- diminishes left and right hemisphere integration
MUPS
Medically unexplained Physical symptoms
Somatization disorder
Criteria at some point:
- 4 pain symptoms
- 2 non-pain GI symptoms
- 1 sexual complaint
- 1 pseudo-neurological complaint
Not explained by other condition
Not intentional
Somatization disorder clinical features
Patients describe themselves as "sickly" -circumstantial, vague, inconsistent, disorganized history -dramatic exaggerated claims many OP visits Frequent IP visits Subspecialty referrals Many diagnoses multiple meds
Clues to somatization disorder
- Multiple organ systems
- early onset and chronic course without physical signs or structural abnormalities
- absence of lab abnormalities
Somatization Tx
Scheduled regular visits
Focused brief exam
Look for objective signs of disease- be skeptical
Avoid excess tests, inasive treatment, referrals, and IP
explain that stress can cause symptoms
set limits on contacts outside of visits
- CBT effective
- Not responsive to long term insight oriented psychotherapy
- Short term dynamic therapy helps
Psychopharm:
Antidepressants show partial response (unknown long term efficacy)
Conversion disorder
- 1 or more voluntary motor or sensory symptom of supposed neurological origin preceded by a stressor (V no stressor)
- clinical findings incompatible with symptom presentation and recognized medical/neuro illness
- 1/3 have real neuro disease
- 25% recur in 1st year
Conversion disorder clinical features
- La belle indifference”
- symptoms follow stress
- symptoms conform to patients understanding of neurology
- inconsistent physical exam
Conversion disorder Tx
- Conservative
- suggestible- We are sure you will improve with a few sessions of physical therapy
- psychotherapies
- amytal interview/hypnosis
Conversion disorder prognosis
Good:
- onset after stressor
- prompt treatment
- Paralysis, aphonia, blindness
Bad:
- delayed treatment
- siezure
Pain disorder
- Pain predominates focus and is severe enough for clinical eval
- complaints significantly change with psychological factors
- genesis of pain
- severity of pain
- Maintainance of pain
- pain not intentionally produced or feigned
Hypocondriasis [Illness anxiety disorder]
- fears of serious illness
- not delusional in intensity and not restricted to concern of appearance
- > 6 months
- [Somatic symptoms if present are mild]
- [High health anxiety and easily alarmed about health]
Hypochondriasis Tx
Cultivate DPR
CBT
Supportive therapy
SSRIs
Body dysmorphic disorder [OCD anxiety disorder]
- Pervasive feeling of ugliness despite normal or near normal appearance
- Concern of any anomaly is markedly excessive
- [repetitive behaviors or mental acts in response]
BDD features
- 12% derm patients, 6-15% cosmetic surg
- 15-30 YO
- Think about flaw (usuallyface or head) 3-8 hrs/day
- compulsive behavior to examine, improve, seek reassurance, or hide defect
BDD Tx
- DO NOT TRY TO FIX / CREATE IATROGENIC HARM
- CBT
- SSRIs- HIGH DOSE LONG DURATION
Facetious disorder
- Intentionally exaggerates or induces SSx
- Motivation to assume sick role
- No external motives
(10% Münchausen -severe and chronic)
(by proxy- someone else i.e. mother smothers child)
(Gansers - approximate answers)
- many suffered childhood abuse (hospitals safe),or childhood health problems
- may be means of increasing self esteem
- associated with medical paraprofessionals, and Borderline personality disorder
