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


Producing a Formulation, Differentiating between Distress and Disorder, Psychosomatic Disorders Dr. James Rodger Consultant Child & Adolescent Psychiatrist, South ... – PowerPoint PPT presentation

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

Producing a Formulation, Differentiating between
Distress and Disorder, Psychosomatic Disorders
  • Dr. James Rodger
  • Consultant Child Adolescent Psychiatrist, South
    Devon CAMHS

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

Differentiating between Distress and Disorder
Correct answer?
  • 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?)

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)

  • 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)

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
  • More rigourous exclusion (psychosis, PDD, mood,
  • Prevalence rates much lower (lt50) using ICD

Prevalence - UK
  • British Child and Adolescent Mental Health Survey
    1999 (ngt10,000)
  • parents / teachers impairment (?clinical
  • 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)

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

  • 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

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?

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

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

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
  • 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?

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?

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

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

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

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).

The place of values
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

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

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

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."

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

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!?

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

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

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
  • diagnostic vs. nosological validity

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

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

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
  • 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?

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

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
  • 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
  • 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

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
  • 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

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

  • 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

  • ?unemployment (67 vs. 40 controls)
  • antisocial / personality dysfunction
  • substance misuse
  • ?criminality (juvenille and adulthood)
  • ?road traffic violations and RTAs
  • seperate but correlated factors in factor
    analysis ? seperate dimensions / traits of the

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
  • 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.

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
  • in adult life it may be a sustained inner sense
    of restlessness.

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

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

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

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
  • V Global assessment of functioning score

ICD-10 Multi-axial diagnostic formulation
  • I clinical disorders (mental and general medical
    conditions) include personality developmental
  • 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).

DSM-V Cultural Formulation
  • What problems or concerns bring you to the
    clinic? what troubles you the most about your
  • 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?

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

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,
  • Impact (how much distress or impairment does it
  • Risks
  • Bio-psycho-social
  • Predisposing / precipitating / perpetuating /
    protective factors
  • Strengths
  • What assets are there to work with?
  • Explanatory model

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
  • 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

Should formulation include impact of diagnosis
  • 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)

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
  • Would meet DSM-IV criteria for ADHD
  • Would this be hlepful to give?

  • 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
  • e.g. Labelling a child who is victim of CSA with

Case HW
  • 14 yr m
  • Voice hearing (command violence self/other)
    involved relationship with voices
  • Triggered by hearing G/F tell him of physical
  • 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

Psychotherapeutic Formulation
  • Psychodynamic
  • Attachment
  • Systemic (include cultural)

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

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
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
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

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
  • Somatisation
  • Spirit possession / sorcery / psychotic
  • Symptoms as attachment strategies
  • eliciting care

Psychosomatic Disorders
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

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
  • Symbolic resolution (unable to walk fear of own
    aggression? Blindness a refusal of desire?)
  • Naïve notions of neurology (children, uneducated,
  • Conforming to perceived expectation of parent /

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

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?

Disorders of somatisation relevant to childhood /
  • Somatisation disorder (roots in adolescence)
  • Undifferentiated somatoform disorder
  • Hypochondriasis
  • Body dysmorphic disorder
  • Conversion disorder (but dissociation ?normative
    in younger children)
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