Current Clinical Strategies, Psychiatry History Taking (2004)

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context of psychosocial stressors, such as
divorce or financial hardship.
II. Etiology. Dissociative phenomena are consid�
ered immature psychological defense mecha�
nisms, which protect against experiencing the
pain of trauma.
III. Clinical evaluation
A. The history of present illness should
focus on the nature of the symptoms and try
to differentiate from among the dissociative
disorders.
B. Dissociative amnesia typically has an
abrupt onset, and the patient is aware of the
memory loss. Memory loss may be localized
for a specific period of time, selective for
certain events, or generalized across a
lifetime.
C. In dissociative fugue, patients wander
away from home for hours to days and may
assume another identity. Unlike dissociative
amnesia, patients in a fugue state do not
recognize their memory loss or identity
confusion.
D. Dissociative identity disorder was previ�
ously called multiple personality disorder. It
is characterized by two or more distinct
identities that alternate in controlling the
patient s behavior. The patient may refer to
himself as we, and typically the patient
does not recall time spent in alternate self�
states. Patients with dissociative identity
disorder may not recognize the existence of
different identities within themselves.
E. In depersonalization disorder, patients
have a sense of detachment from them�
selves, and may describe feeling unreal, or
in a dream-like state. Patients may also
describe observing themselves from a
distance. Depersonalization symptoms are
experienced as abnormal and distressful,
although a non-pathological variant that is
not distressful to the patient also exists.
IV.Treatment
A. Inpatient hospitalization is rarely neces�
sary unless symptoms of comorbid psychiat�
ric disorders are present and require admis�
sion. It is possible that alternate identities in
dissociative identity disorder may exhibit
impulsivity and suicidal or homicidal behav�
ior, which mandates hospitalization.
B. Benzodiazepines, barbiturates, hypnosis,
and relaxation techniques may all be useful
to facilitate recall in amnesia.
C. Psychotherapy may help patients to recog�
nize the impact of past traumatic events and
address the associated pain with improved
coping strategies.
References, see page 92.
Somatization - History Taking
History of present illness: Current symptoms,
duration, date of onset, psychosocial stressors,
and associated distress. Ask about pain, gastroin�
testinal distress, sexual dysfunction, and neuro�
logical symptoms. Somatization disorder is as�
sessed by asking about pain, nausea, vomiting,
bloating, diarrhea, and constipation. Decreased
libido, erectile or ejaculatory dysfunction, irregular
menses, and menorrhagia. Weakness, paralysis,
loss of balance, sensory deficits, difficulty swal�
lowing, blindness, double vision, and seizures.
Conversion disorder symptoms appear neurologi�
cal in origin and may consist of deficits in any
sensory or motor system. A fear of having a
medical illness suggests hypochondriasis. Body
dysmorphic disorder is assessed by asking about
preoccupation with an imagined bodily defect and
perceived misshapen body parts, such as hair,
nose, skin, eyes, and mouth.
Past psychiatric history: Ask about past hospi�
talizations, diagnoses, treatments, and suicide
attempts. Previous conversion symptoms, depres�
sion, anxiety, schizophrenia, and histrionic per�
sonality disorder are seen more frequently as
comorbid illness in somatoform disorders.
Substance abuse history: Alcohol, cocaine,
heroin, marijuana, hallucinogens, sedatives,
hypnotics, anxiolytics, and analgesics. Substance
abuse occurs more frequently in patients with
somatization disorder and increases the risk of
suicide.
Social history: Living situation, family relation�
ships, level of education, income, history of physi�
cal or sexual abuse, and psychosocial stressors,
such as loss of a loved one, marital conflict, and
divorce. Conversion symptoms are more likely to
occur in patients with a low level of education, low
socioeconomic status, a history of abuse, and in
the context of psychosocial stressors.
Family history: Substance abuse, cluster B
personality disorders, and somatization disorder
occur more frequently in family members of
patients with somatization disorder.
Past medical history: Ask about past medical
illness, hospitalizations, surgeries, and neurologi�
cal problems. Dementia, brain tumors, myasthenia
gravis, multiple sclerosis, systemic lupus
erythematosus, seizures, acute intermittent
porphyria, polymyositis, HIV, and Guillain-Barre
syndrome can all cause symptoms that mimic
somatization disorder and conversion disorder.
Medications: Medical, alternative, and all over�
the-counter medications.
Mental Status Exam
General appearance: Calm and cooperative; the
patient may not exhibit an appropriate level of
concern about symptoms.
Speech: Normal rate, rhythm, and volume.
Mood: Scared, upset or depressed.
Affect: Dysphoric or anxious. The patient may
show inappropriate (incongruent) affect when
describing potentially serious symptoms.
Thought process: Linear and goal-directed, but
often ruminative about symptoms.
Thought content: Illogical. Ideas of reference of
people noticing the perceived defect may occur in
body dysmorphic disorder. Concern about symp�
toms and fear of illness do not reach delusional
proportions in somatoform disorders.
Perceptual: Denies hallucinations or illusions.
Suicidality: Denies active suicidal ideation, but
may have a history of suicide attempts.
Homicidality: Denies.
Sensorium/cognition: Alert and oriented; intact
memory and concentration, and good fund of
knowledge.
Impulse control: Fair. There is no evidence of
poor impulse control.
Judgment: Fair. The patient is aware of effect
behavior may have on others.
Insight: Limited. The patient does not understand
the psychological nature of symptoms.
Reliability: Fair. The patient describes symptoms [ Pobierz całość w formacie PDF ]

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