Producing a Formulation, Differentiating between Distress and Disorder, Psychosomatic Disorders

1
Producing a Formulation, Differentiating between
Distress and Disorder, Psychosomatic Disorders

• Dr. James Rodger
• Consultant Child Adolescent Psychiatrist, South
  Devon CAMHS

2
Overview

• Differentiating distress from disorder what the
  manuals tell us
• Beyond impairment models of disorder
• Validity of mental disorder
• Formulation
• Somatisation

3
Differentiating between Distress and Disorder
4
Correct answer?

• DSM-IV-TR
• polythetic symptom criteria
• episode fit (is there a better fit?) /
  developmental criteria / duration criteria
• causing clinically significant distress or
  impairment (educational, occupational, social,
  family life)
• D diagnostic fit (superordinate diagnosis,
  organic causes excluded?)

5
Case example - ADHD

• The DSM criteria - two groups
• Inattentive (9) and hyperactive-impulsive (63)
  symptoms (inconsistent with developmental level)
• Six of the nine symptoms in each section must be
  present for a combined type diagnosis of ADHD.
• if insufficient symptoms for a full diagnosis
• predominantly inattentive (ADHD-I)
• predominantly hyperactive (ADHD-H)
• Supported by factor-analysis studies
• most studies supporting a two-factor model of
  symptom clustering (as above)

6
DSM-IV-TR

• symptoms must be chronic (gt 6 months) and present
  before age 7
• symptoms present in 2 or more settings but
  evidence of significant impairment required in
  only one setting (social, school or work)
• not occuring exclusively in context of PDD or
  psychosis, not better accounted for by another
  disorder (e.g. Anxiety, ?RAD)

7
ICD-10 hyperkinetic disorders

• Almost identical symptom list but need symtom
  count in all 3 domains accross gt2 contexts
• 6/9 inattentive
• 3/5 hyperactive
• 1/4 impulsive
• Significant distress or impairment 1 or more
  contexts
• More rigourous exclusion (psychosis, PDD, mood,
  anxiety)
• Prevalence rates much lower (lt50) using ICD

8
Prevalence - UK

• British Child and Adolescent Mental Health Survey
  1999 (ngt10,000)
• parents / teachers impairment (?clinical
  process)
• 3.62 of boys and 0.85 of girls had ADHD
• 4.251 MF.
• more restricted diagnosis ICD10-hyperkinetic
  ? ?prevalence ?1.5 for boys (primary school)

9
Natural Rates of ADHD!

• UK prevalence estimate up to 16 (Taylor 1991)
• In USA prevalence estimates 8-25
• Worldwide high variability (DSM-IV)
• Low Australia 2.4 10 (DSM-IV
• High Brazil, Colombia, Germany, Ukraine 15-20
• majority of variability ? methods used
• Criteria
• Rating scales vs. more in depth interview
• Impairment
• Sources of information (single / multiple)
• minor differences worldwide (NICE) 5.3

10
Impairment

• Fundamental to diagnostic validity (as ADHD
  symptoms on spectrum with normal population)
• Without criterion of impairment ? 2x ? prev
• Newcastle (McArdle et al., 2004).
• 11 if no impairment
• 6.7 moderately low impairment
• 4.2 for moderate impairment
• 1.4 for severe pervasive impairment

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Is distress and/or impairment enough?

• Being gay can be very distressing, if you, or
  your family, or wider society dont want you to
  be but we dont call homosexuality a. err
  burn the previous editions
• Roland Littlewood a psychiatrist and
  anthropologist describe a woman in her 30s, who
  by our standard would have met all several
  criteria for schizophrenia, but was not
  distressed, and formed a new religious movement
  Mother Earth with many followers - therefore
  no dsyfunction?

12
Biomedical Definitions

• biological disadvantage (Scadding 1967)
• that it must at least encompass reduced fertility
  and life expectancy (Kendell (1975)
• Are we happy for this to be our primary
  evaluative criterion for thinking about the value
  of human life?
• Life style choices, homosexuality, and life
  within religious orders, may all be patholgised
  by such a definition!
• Illogical consequences when applied to thinking
  about mental disorder
• Many milder conditions such as phobias as well as
  disorders with onset after the prime reproductive
  years would fail to qualify as disorders and may
  not affect life-expectancy either
• Conduct disorder may confer evolutionary
  advantage!

13
Biomedical Disadvantage Failure of
Evolutionary Design?

• dysfunction - failure of a biological mechanism
  to perform a natural function for which it had
  been designed by evolution (Wakefield 1992)
• Too little known about the evolution of most of
  the higher cerebral functions
• Mood states such as anxiety and depression may
  have evolved as biologically adaptive responses
  to danger or loss
• Paranoia ,hearing voices OCD, may have
  conferred evolutionary advantage, during EEA
  (Pleistocene 1.8million 12,000 years ago)
• Some cognitive abilities, like reading, have been
  acquired too recently to be plausibly regarded as
  natural functions designed by evolution

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Can dysfunction be defined without reference to
evolution or disadvantage?

• too little is known about the cerebral
  mechanisms underlying basic psychological
  functions, such as perception, abstract
  reasoning, and memory, for it to be possible in
  most cases to do more than infer the probable
  presence of a biological dysfunction??
• i.e. need a frame of reference to say whether
  pathology
• Furthermore, rejecting both the evolutionary and
  biological disadvantage criteria may open the way
  to regarding a wide range of purely social
  disabilities (such as aggressive, uncooperative
  behaviour or an inability to resist lighting
  fires or stealing) as mental disorders.
• Is this already happening?

15
Sociopolitical Definitions

• disease is simply what doctors treat!
• Although rarely advocated by physicians -
  treatability is often a crucial consideration
  underlying their decisions to regard individual
  phenomena as diseases
• despite the advocacy of Thomas Trotter and
  Benjamin Rush at the beginning of the nineteenth
  century and a sustained campaign by Alcoholics
  Anonymous in the 1930s, the medical profession
  firmly resisted the proposal that alcoholism
  should be regarded as a disease until disulfiram
  (Antabuse) was introduced in the late 1940s
• As for Ritalin and ADHD gtlate 1960s?

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Sociopolitical Definitions

• Condition is regarded as a disease if it is
  agreed to be undesirable (an explicit value
  judgment) and if it seems on balance that
  physicians (or health professionals in general)
  and their technologies are more likely to be able
  to deal with it effectively than are any of the
  potential alternatives, such as the criminal
  justice system (treating it as crime), the church
  (treating it as a sin), or social work (treating
  it as a social problem).
• essentially pragmatic or utilitarian.
• given condition might be a mental disorder in one
  setting but not in another - depending on the
  relative efficacy of medical and other approaches
  to the problem in those different settings

17
Sociopolitical Definitions

• whether restless, overactive children with short
  attention spans are regarded as having
  attention-deficit/hyperactivity disorder or
  simply as being difficult children would depend
  on whether child psychiatrists were better at
  ameliorating the problem than parents and teachers

18
Combined biomedical and sociopolitical definition

• concept of mental disorder necessarily involves
  both a scientific or biomedical criterion
  (dysfunction) and an explicit value judgment or
  sociopolitical criterion harm (Wakefield
  1992/99) or handicap (WHO)
• meets the main requirement of both the
  sociopolitical and the biomedical camps
• seems to reflect the often intuitive ways in
  which physicians make disease attributions for
  physical disease
• value judgements may vary accross cultures, and
  would be important even if concrete biological
  substrates discovered
• Nailing down assured biological dysfunction, may
  still be elusive, and definition may slide
  towards purely sociopolitical definitions, masked
  by pseudo-science?
• ODD...CD.... .....(ADHD?)
• Also c.f. Neurodiversity Movement

19
ADHD as a case example controversies

• ADHD is total, 100 percent fraud Fred
  Baughman - Pediatric neurologist (2006)
• ADHD is real, a real disorder, a real problem,
  often a real obstacle Russell Barkley, leading
  ADHD researcher (1995)
• you ask me, any kid who would rather go outside
  and play, than to sit in school all day sounds
  pretty normal to me (Yahoo Questions 2008).

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The place of values
21
Who is it a problem for?

• cultural differences in the level of activity and
  inattention that is regarded as a problem
  (Sonuga-Barke et al., 1993)
• teachers and parents tolerance and ability to
  cope may determine whether the hyperactivity is
  presented as a problem
• Children with hyperactivity rarely ask for help
  themselves

22
Male Female

• Clinic referred 101
• Community referred 31
• Disruptive behaviour drives referrals?

23
An androgenist critique

• Quantified Observation
• ethological observation and activity monitoring
  confirmed that teachers more likely to attribute
  symptoms of ADHD to boys than girls after
  correction for actual behaviour differences
  (Brewis et al. 2003)
• Mothers and female teachers statistically more
  likely to initiate process of diagnosis and
  treament for ADHD, than fathers / male teachers
  who may view behaviour as more normative

24
Case Study homosexuality

• Sexual Orientation Disorder (DSM-II revision
  1974) / Ego-dsytonic homosexuality (DSM-III 1980)
  located the problem within the psychologies of
  gay people, rather than within the society who
  stigmatised and discriminated against them
• DSM-IV (1994) ego dystonic homosexuality
  dropped, but included "sexual disorder not
  otherwise specified" which could include
  "persistent and marked distress about ones
  sexual orientation."

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Challenges to this definition

• Therapeutic challenges
• Recovering subjugated narratives of strength
• Explicating social causes of suffering (poverty,
  discrimination etc.)
• Diagnostic challenges
• Relational Disorders in DSM-V but limited scope
  (e.g. domestic violence, post-partum depression)
• Political challenges
• Neurodiversity
• Critical Psychiatry

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Ostensive Definition

• Impossible, even in principle, to provide a
  semantic or operational definition of the
  global concept of mental illness or disorder,
  only of individual illnesses or disorders
  (Lilienfeld and Marino 1995)
• The only criterion available is whether putative
  or candidate disorders are sufficiently similar
  to the prototypes of mental disorder (e.g.
  schizophrenia and major depressive disorder)
• The best definition remains a circular one!?

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Levels of Explanation

• Even physical disease cannot be defined by one
  overaching definition
• Clinical syndrome migraine and torticollis
• Morbid anatomy mitral stenosis
• Histopathology tumours
• Chromosomal architecture Down syndrome
• Molecular structures thalasemmias
• what is the most useful level of explanation
  (utility!) yielding the most useful information
  for action for a given presentation
• May be reciprocally influenced by treatment
  available. Current treatments for torticollis
  dont demand a molecular level understanding,
  even if this was available

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Why are different levels of explanation required?

• more a particular presentation looks similar to
  others but responds differently - the more
  complex the level of explanation needs to be?
• Most psychiatric disorder still defined by
  clinical syndrome current drug treatments dont
  justify a more complex biological description
• But they do justify a more complex psycho-social
  / systemic description e.g. diffential
  explanations for symptoms of hyperactivity and
  inattention

29
What do we mean by validity?

• valid validus strong
• defined as well founded and applicable sound
  and to the point against which no objection can
  fairly be brought
• Logic validity is the characteristic of an
  inference that must be true if all its premises
  are true.
• there is no single, agreed upon meaning of
  validity in science, although it is generally
  accepted that the concept addresses the nature
  of reality
• its definition is an epistemological and
  philosophical problem, not simply a question of
  measurement
• diagnostic vs. nosological validity

30
Establishing Validity Feigner Criteria

• Robins Guze (1970) / Feighner (1972)
• Clinical description
• Labaratory Studies (i.e. to show biological
  dysfunction includes cognitive profile?)
• Delimitation from other disorders (c.f. zone of
  rarity Kendell 2003)
• Follow-up studies (diagnostic stability
  response to Rx and outcome)
• Family studies

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Diagnostic Validity(According to NICE)

• Do Symptoms of inattention, hyperactivity
  cluster together
• Can they be distinguished from normal variation
  in the population?
• Are they distinguishable from other disorders
• Are symptoms asociated with significant clinical
  and psychosocial impairments?
• Are there characteristic outcomes?
• Is there consistent evidence of genetic,
  environmental or neurobiological risk factors?
• Risks overlap / confluent with risks in normal
  population depending on method used

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Different Validators Different Answers

• a hierarchy of validators must first be chosen
  for a given nosologic question
• involves a value judgment and cannot be directly
  addressed by empirical inquiries
• What is the core feature of schizophreniathat
  it has a poor outcome, its Sx or that it runs in
  families?
• This is not a scientific question.
• only once nosological question is set, can task
  of formulating maximally valid diagnostic
  criteria even begin to occur
• Could compare different diagnostic criteria for
  utility, in different contexts
• DSM-V may rate relative validity of different
  diagnosis but based on what?

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Validity vs. Utility (Kendell Jablensky 2003)

• Few psychiatric diagnosis can claim nosological
  validity, according to Feighner criteria
  (especially hard for laboratory studies
  delineation from other disorders)
• Moving to validity for specific questions, or
  context-based, moves away from notion of
  universal truth to notion of utility
• Psychiatric diagnosis cannot claim to be valid,
  but can claim to be useful in certain contexts
  

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The Case for Dimensional Classification

• Most disorders lack a zone of rarity
• Genetic and environmental risk cut accross
  diagnoses, as do symptoms, and treatments (e.g.
  depression anxiety somatisation / psychotic
  bipolar)
• Would circumvent need for multiple diagnoses, of
  unclear validity or utility (treat all?)
• Clinicians less pressured to make Procrustean
  decisions - forcing diverse presentations into
  best fit categories
• Less information is lost
• Particularly helpful for trans-cultural work,
  where diagnostic categories perceived even more
  problematic
• Emerging ideas in pharmacotherapy, suggest
  medication may target symptoms, not syndromes
  response easily measured
• Reduction of stigma, through normalisation with
  general population, and lack of labelling

35
ADHD validity according to Feighner criteria

• Clinical description symptom clusters
• Impairment culture-context specific?
• Laboratory Studies
• Neuroimaging studies (structural functional)
  not drug naive (even if unmedicated at time of
  imaging)
• Functional imaging also tautologous!
• Distinguishes from other conditions, including
  effects of maltreatment?
• Not well delimited from other disorders, e.g.
  paediatric bipolar, emerging emotional unstable
  personality disorder (impulsive subtype) and RAD

36
ADHD validity according to Feighner criteria

• Does high heritability cannot distinguish
  environment from genetic influence?
• Twin studies wrongly assume equal environment (DZ
  vs MZ)?
• Adoption studies methodologically weak often
  unblinded, lack adoptee control group (confounds
  attachment problems), and do not account for
  pre-adoption / pre-natal experience
• Individual genes weak effect, non-specific - how
  to inherit multiple genes of small effect
• DRD4-7 repeat (one of the highest RR 1.45) also
  linked with attachment disorganisation, but only
  in presence of unresolved maternal loss / trauma
• Follow-up highly variable, depending on other
  contextual factors

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OUTCOMES

• persistence of symtpoms / impairment
• better prognosis if problem is inattention alone
• poor school achievement
• 32 fail to complete high school
• higher rate of disruptive behaviour disorders
• lack of friends / ?peer problems
• lack of constructive leisure activities

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OUTCOMES

• ?unemployment (67 vs. 40 controls)
• antisocial / personality dysfunction
• substance misuse
• ?criminality (juvenille and adulthood)
• ?road traffic violations and RTAs
• POOR OUTCOMES MEDIATED / MAGNIFIED BY DEVELOPMENT
  OF CONDUCT PROBLEMS
• seperate but correlated factors in factor
  analysis ? seperate dimensions / traits of the
  disorder

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Adult ADHD

• Recognition of persistence into adult life
• 15 of those diagnoses still meet full criteria
  by age 25 ? prevalence 0.6-1.2 (childhood 4-8)
• 65 persistence of some Sx (DSM partial
  remission)
• criteria may be biased towards younger
  developmental stages
• Inattention may ? and attention span usually will
  usually ? with age
• lag behind that of unaffected people and that
  necessary / expected for attainment.

40
Adult ADHD

• Evolution of Sx
• in pre-school child incessant and demanding
  extremes of activity
• during school years child may make excess
  movements during situations where calm is
  expected rather than on every occasion
• in adolescence hyperactivity may present as
  excessive fidgetiness rather than whole body
  movement
• in adult life it may be a sustained inner sense
  of restlessness.

41
Establishing Validity Feigner Criteria

• Robins Guze (1970) / Feighner (1972)
• Clinical description
• Labaratory Studies (i.e. to show biological
  dysfunction includes cognitive profile?)
• Largely non-specific
• Delimitation from other disorders (c.f. zone of
  rarity Kendell 2003)
• Few disorders truly seperate
• Follow-up studies (diagnostic stability
  response to Rx and outcome)
• Highly variable for many disorders
• Family studies
• Disorders overlap

42
Producing a Formulation

• A key advantage of formulation over diagnosis is
  that it can be used to predict how an individual
  might respond in certain situations and to
  various psychotherapies or other interventions

43
Standard textbook approach

• Socio-demographic summary
• Presentation
• Diagnoses / differentials
• Presumed aetiologies
• Management plan
• Predicted response
• implicitly linked to accuracy of formulation

44
DSM-IV Multi-axial evaluation

• I Clinical disorders
• II Personality disorders / learning disability
• III General medical conditions
• IV Psychosocial and environmental problems, inc
• problems related to primary support group
• Educational problems
• Problems with housing / economic / social
  environment
• V Global assessment of functioning score

45
ICD-10 Multi-axial diagnostic formulation

• I clinical disorders (mental and general medical
  conditions) include personality developmental
  dimensions
• II disabilities (in personal care, occupational
  functioning, functioning with family, and broader
  social functioning / social roles)
• III contextual factors (interpersonal and other
  psychosocial and environmental problems)
• IV quality of life (primarily reflecting
  patient's self-perceptions, including spiritual
  culturally informed).

46
DSM-V Cultural Formulation

• What problems or concerns bring you to the
  clinic? what troubles you the most about your
  problem?
• How would you describe to others not doctors?
  Is there a particular term / cultural label?
• Why do you think this is happening to you? What
  do you think are the particular causes of your
• What have your family, friends, and other
  people in your life done that may have made your
  PROBLEM better/worse?
• Is there anything about your background, e.g.
  your culture, race, ethnicity, religion or
  geographical origin that is causing problems/
  helping in your current life situation?
• REFLECTING ON CULTURAL IDENTITY AS SOURCE OF
  STRENGTH OR OTHERWISE

47
DSM-V Cultural Formulation

• Clarify self-coping for the problem listen for
  mental health treatment, medical care, support
  groups, folk healing, religious or spiritual
  counseling, or other alternative healing.
• Barriers to help-seeking, access to care, and
  problems engaging in previous treatment.
• Is there anything about my own background that
  might make it difficult for me to understand or
  help you with your PROBLEM?
• Establish goals and treatment preferences

48
SIRSE framework (from Child Psychiatry, 2nd Ed
Goodman and Scott)

• Symptoms
• Emotional
• Conduct
• Developmental (include attention-activity
  levels-impulsivity, speech/language, play, motor,
  toilet training, learning literacy / numeracy)
• Social relatedness peers, family, authority,
  strangers
• Impact (how much distress or impairment does it
  cause?)
• Risks
• Bio-psycho-social
• Predisposing / precipitating / perpetuating /
  protective factors
• Strengths
• What assets are there to work with?
• Explanatory model

49
An additional frameworkRutter, Taylor Hersov
CAAP, Modern Approaches

• Does the child have a psychiatric disorder?
• If there is a disorder does the clinical picture
  fit that of a recognized clinical syndrome?
• What are the various roots of that disorder in
  terms of intrapsychic, family, sociocultural and
  biological factors and what are the relative
  strengths of each of these root causes in this
  particular patient?
• What forces are maintaining the problem?
• What forces are facilitating the childs normal
  development?
• What are the strengths and competencies of the
  child and of the family
• Untreated what is the likely outcome of the
  childs disorder(s)?
• Is intervention necessary in this case?
• What types of intervention are most likely to be
  effective?

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Should formulation include impact of diagnosis
itself?

• Theoretically we can hold multiple levels of
  explanation in mind simultaneously
• in practice it can be difficult not to privilege
  one level (hard for professionals, even harder
  for families?)
• different levels may have contradictory
  implications for action
• Whether intended or not, classification reifies
  disorder as a fixed, and real entitiy, located
  within the individual
• a problem in psychiatry because psychiatric
  illness, may be more responsive to changes in
  meaning and social context, than physical illness
• Impact of diagnosis, and contingent social stigma
  on self-identity (which may already be less
  developed and robust)

51
Case KB

• 8 yr old presenting Sx ADHD / ODD
• Mum victim of CSA
• CP chronology reveals pervasive Hx of neglect,
  emotional and physical maltreatment and exposure
  to DV
• Impact on children minimised by mother
• Significant Speech Language difficulties
• Receptive (ToM) and expressive (internalised
  dialogue)
• Would meet DSM-IV criteria for ADHD
• Would this be hlepful to give?

52
Formulation

• A hook to hang it all on!
• A cook-book / symptom checklist approach to
  diagnosis may lead to multiple medications (c.f.
  Louis Theroux in America!) and have catastophic
  consequences
• e.g. Labelling a child who is victim of CSA with
  ADHD

53
Case HW

• 14 yr m
• Voice hearing (command violence self/other)
  involved relationship with voices
• Triggered by hearing G/F tell him of physical
  abuse
• Some prior drug use
• Sees himself as black sheep family withdrawal
  longstanding (prognostic / Rx significance)
• Peers streetwise, but non-confiding
• Voices reminiscent of protracted bullying
  evolves into protector rules of living
• Cf. Steiner psychic retreats

54
Psychotherapeutic Formulation

• Psychodynamic
• Attachment
• Systemic (include cultural)

55
Systemic Formulation

• Cybernetics homeostasis / feedback
• Structural hierarchies / boundaries
• Transitions / family life cycle
• Functional what cause is the Sx serving?
• Beliefs and communication difference and how
  this is understood and communicated
• Narrative how the problem is talked about is
  part of the problem

56
3 column systemic formulation(Carr 2006)
Contexts Belief systems Behavioural patterns
Family of origin issues Beliefs about change
Social educational professional networks Acknowledged and hidden strengths (subjugated narratives Foucault)
Constitutional factors - Can include medical Disorder, deficit, disability reframing, externalising
57
Attachment From Behaviour to Representation
Attachment classification SST / AAI Strange Situation Test (SST) Adult Attachment Interview (AAI)
Secure / Autonomous Cries briefly on separation, happy on reunion, secure base from which to explore Coherent and relevant, appropriate examples, able to acknowledge episodes of distress without overwhelmed
Anxious-ambivalent / preoccupied - enmeshed Distraught on separation, clingy-inconsolable on reunion, cannot explore Bound up in feeling, stories and relationships from the past, winding, overlapping stories, without clear resolution
Anxious-avoidant / dismissing Indifferent on separation and reunion, focused on inanimate object-play overly brief, keen to move onto next question, poverty of description, idealisation without evidence to back up.
Disorganised / unresolved Freezing, oscillation approach-avoidance, anamolous Hard to follow narrative, jumping from past to present, or speaking about past as if present, pronoun confusion
58
Hypothesized Parenting Styles

• Secure attuned, able to think about childs
  needs separate from their own, flexible but able
  to set boundaries
• Dismissing harsh, unreflecting, parenting style,
  parents unable to attend to childs emotional
  needs (or their own), child learns to not feel
• Preoccupied parent may be intermittently
  available but inconsistently so child learns to
  amplify distress to get their needs met
• Unresolved frightened or frightening parent
  may be linked to parental unresolved grief or
  maltreatment

59
Family ( cultural) scripts

• Characteristic modes of relating and
  communicating distress that run in families
• Risk taking
• Dramatic histrionic
• Medicalising / somatising
• Cultural idioms of distress and CBS
• Overdosing (Western shunned in traditional
  soc)
• Somatisation
• Spirit possession / sorcery / psychotic
  behaviour
• Symptoms as attachment strategies
• eliciting care

60
Psychosomatic Disorders
61
Formulations of somatic Sx

• Family / cultural script
• may also be universal characteristic of
  mood-anxiety states, selected or de-selected from
  awareness by culturally influenced cognitive
  processes (automatic somatic-scanning)
• Children less enculturated therefore somatic
  complaints more common
• May include cultural understandings of what
  doctors want to hear
• Somatisation disorder / Sx much more commonly
  reported and Dx by physician interviewer
• Children, less educated / illiterate persons, or
  those with LD may have more naïve notions of
  medicine

62
Conscious or unconscious?

• Conscious
• Fictitious (or malingering (sic))
• Induced (by child or parent, or for parent)
• Unconscious
• Dissociative conversion (Freud hysteria)
• Intrapsychic conflict (aggressive / sexual
  impulses)
• Symbolic resolution (unable to walk fear of own
  aggression? Blindness a refusal of desire?)
• Naïve notions of neurology (children, uneducated,
  LD)
• Conforming to perceived expectation of parent /
  doctor!

63
Unconscious (cont..)

• Traumatic dissociation (Janet)
• Flashbacks, intrusion of visual memory
• Pain, intrusion of somatic memory
• Emotional numbness, emotions split off in
  dissociated self
• Sensory loss, ongoing pain or memory off split
  off in dissociated self
• Functional (systemic hypothesis)
• Symptom serving a function within wider family
  system e.g. to unite parents, derail conflict
• Attachment / scripts / conscious - unconscious

64
Case KK

• 17 yr F
• CAMHS 15 depression / anxiety
• Hx domestic violence exposure ?
• Hit and run RTA ? PTSD ? Litigation
• Enmeshed relationship with mother co-dependent
  (separation anxiety driven by?)
• Ongoing Sx PTSD physical pains
• Ambivalent engagement
• Attachment script / pattern secondary gain
  fear of change?

65
Disorders of somatisation relevant to childhood /
adolesence

• Somatisation disorder (roots in adolescence)
• Undifferentiated somatoform disorder
• Hypochondriasis
• Body dysmorphic disorder
• Conversion disorder (but dissociation ?normative
  in younger children)