DOCSLIB.ORG

Problems in Family Practice a Clinical Approach to the Somatizing Patient

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Problems in Family Practice a Clinical Approach to the Somatizing Patient Problems in Family Practice A Clinical Approach to the Somatizing Patient Robert C. Smith, MD East Lansing, Michigan Patients with chronic, unexplained physical complaints are evaluated diagnostically in two steps in primary care: (1) brief consideration of three specific, but rare, disorders (somatic delusion, conversion, and malingering); and (2) extensive consideration of the remaining three common but overlapping disorders (somatization disorder, hypochondriasis, and psychogenic pain). Because of frequent confusion in differ­ entiating among the common somatizing disorders and be­ cause the treatment is similar for all, the family physician can be content with the general designation of “common somati­ zation syndrome” when unable to distinguish among them. This diagnosis can be easily established by a good history and physical examination. Psychiatric referral is required for the rare somatizing disor­ ders. The primary physician can manage the majority of the common somatizing patients by observing the following prin­ ciples: develop a good physician-patient relationship, apply techniques of behavior modification, engage the patient at the somatic level but extend it to include associated life stresses, strategically use symptomatic measures, treat depression with full doses of antidepressants, and accept the importance of ongoing contact with the patient irrespective of symptoms. When these therapeutic principles are employed, decreased morbidity, medical utilization, and cost can be expected to follow. Because of their chronic, unexplained physical tion’s Diagnostic and Statistical Manual of Men­ symptoms, somatizing patients have long posed tal Disorders (DSM-III), the majority of disorders diagnostic and therapeutic challenges to phy­ in this group are defined as somatoform disor­ sicians.1"3 In the American Psychiatric Associa- ders,4 the four specific disorders being conver­ sion, somatization disorder, hypochondriasis, From the Departments of Medicine and Psychiatry, Uni­ and psychogenic pain. Two other types of somatiz­ versity of Rochester School of Medicine and Dentistry, ing patients, those with somatic delusions and Rochester, New York. Requests for reprints should be ad­ dressed to Dr. Robert C. Smith, Division of General Internal malingering, are classified elsewhere in DMS-III- Medicine, Department of Medicine, B 220, Life Sciences Somatoform disorders are defined as having phys­ Building, Michigan State University College of Human Medicine, East Lansing, Ml 48824. ical symptoms with no explanatory organic find- 1985 Appleton-Century-Crofts 294 THE JOURNAL OF FAMILY PRACTICE, VOL. 21, NO. 4: 294-301, 1985 THE SOMA THING PA T/ENT ings or known physiologic mechanisms and with most instances, and by their seldom being con­ evidence that the symptoms are linked to psycho­ fused with the clinical characteristics of the com­ logical factors.4 Ford defines somatization some­ mon group. Further, because of the rarity and fre­ what more broadly as a process, usually uncon­ quent association with severe psychopathology, scious, in which the body is used for psychological psychiatric consultation should be obtained to purposes or personal gain5; this explanation en­ guide both diagnosis and treatment. Nonetheless, compasses all six of the foregoing somatizing dis­ the primary physician should remain involved, ac­ orders. It is useful to consider somatization as an cept the problem as real, and protect the patient alternative way (somatic) to express psychiatric from doctor shopping and ill-advised interven­ disease or psychological distress when the patient tions.5 is unable to use the emotional route of ex­ pression.6 Not only is the somatizing patient a common Somatic Delusions problem for physicians,7 representing at least 40 There are two clinical presentations of this percent of a medical outpatient population,8-9 but psychotic disorder14: (1) as an isolated delusional his disease predisposes him to increased morbid­ somatic complaint, and (2) as part of a generalized ity, mortality, and iatrogenic complications.4-5-10 psychiatric disease in which the somatic delusion Further, somatizing patients consume an inordi­ is just one of many psychotic symptoms. With nate portion of the medical care dollar,10 estimated either, the clinical presentation of the somatic de­ to be at least $20 billion per year excluding the lusion takes one of the following three forms14: (1) extensive cost to society from disability and time dysmorphophobia, (2) delusions of bromosis, and lost from work.5 (3) delusions of parasitosis. Patients with dysmor­ Although psychophysiologic, psychosomatic, phophobia believe that the face, nose, hair, and factitious disorders have psychological com­ breasts, or genitalia are deformed and frequently ponents, these disorders are usually associated consult surgeons for reconstructive or other pro­ with well-defined pathologic and physiologic ab­ cedures; it seems reasonable to include patients normalities and should not be confused with the with delusions of internal organ deformity or dys­ somatizing patient.4-11 function15 in this category also. Patients with de­ While unrecognized psychiatric diagnoses are lusions of bromosis have delusions of offensive frequent in primary care,12,13 a recent study of body odors and frequently consult primary care physicians by Oxman et al2 also shows much diag­ physicians and dermatologists. Patients with de­ nostic confusion in distinguishing among the spe­ lusions of parasitosis have delusions of infestation cific somatizing disorders themselves. This paper, by parasites and frequently consult der­ in addition to reviewing the differential diagnosis matologists. The diagnostic task in each is to es­ of the somatizing patient, will attempt to clarify tablish that the patient has deluded thinking. the diagnostic approach by separating the diseases into a rare group (somatic delusion, conversion, and malingering) and a common group (somatiza­ tion disorder, hypochondriasis, and psychogenic Conversion Disorder pain), and then by considering the diagnostically A conversion disorder is conservatively defined confusing disorders in the common group as a in DMS-III as a rare, isolated, and nonpain-related single diagnostic entity when a more precise diag­ neurologic problem such as paralysis, blindness, nosis cannot be made. Finally, a therapeutic ap­ convulsions, mutism, and tunnel vision; it often proach, applicable in primary care, is outlined to occurs with stress in a patient with earlier experi­ aid in the management of somatization. ence with the symptom, and is most often seen in patients who live in rural areas, are uneducated, and are from lower socioeconomic strata.16 Al­ though this paper uses this restricted definition of The Rare Somatizing Disorders conversion, the mechanism of conversion may be This group is united only by the rarity of each more widely applicable.4,15 To establish a diag­ member, a unique clinical presentation of each in nosis of conversion disorder is difficult and usually THE JOURNAL OF FAMILY PRACTICE, VOL. 21, NO. 4, 1985 295 THE SOMA TIZING PA TIENT requires psychiatric and neurologic consultation. Somatization Disorder Under certain circumstances conversion disorder is difficult, if not impossible, to differentiate from This chronic nonremitting disorder involves malingering. In other circumstances, conversion women almost exclusively and always begins be­ disorder has been difficult to distinguish from or­ fore the age of 30 years.4 Fourteen of 37 ganic disease; in follow-up studies of patients with nonspecific somatic complaints, including pain, a diagnosis of conversion disorder, approximately must be present to make this diagnosis. While 25 percent later exhibited organic disease that these symptoms are nonspecific, their style of pre­ could explain the conversion symptom.16 sentation may be more specific.18 Although not part of the DSM-III critiera, a histrionic personal­ ity style is frequently associated with somatization Malingering disorder and, for the most part, is what defines Malingering is the voluntary (conscious) pro­ Briquet’s syndrome.5,18 These patients may ex­ duction of physical complaints to obtain personal press considerable affect, but it is usually super­ gain.4 It can present with any type of symptom and ficial. They frequently show evidence of depres­ can usually be detected when organic disease is sion and often relate chaotic personal lives. There excluded, secondary gain is prominent, and the is also a family history of disrupted upbringing in voluntary nature of the symptoms is detected. It is many, of sociopathy and substance abuse in the important to view malingering as a symptom of men (and husbands), and of hysteria in the underlying psychopathology rather than a disease women.18 entity, since past studies have shown that 90 per­ cent had some type of psychopathology, often a Hypo chon driasis personality disorder.5 Hypochondriasis is also a chronic and non­ remitting disorder, and it involves men and women in equal proportions.4 It may begin at any age but is usually diagnosed in middle and older age. These patients typically present with multiple and nonspecific somatic complaints of virtually any type including pain.19 Their style of presentation, however, may be very specific; in contrast to Briquet's syndrome, the patient’s concern is char­ The Common Somatizing Disorders acteristically obsessive. Their style is very con­ trolled and independent, although a certain subset Because the
Load more

Recommended publications
  • Treating Somatization
    TREATING SOMATIZATION TREATING SOMATIZATION A Cognitive-Behavioral Approach Robert L. Woolfolk Lesley A. Allen THE GUILFORD PRESS New York London © 2007 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:987654321 LIMITED PHOTOCOPY LICENSE These materials are intended for use only by qualified mental health profes- sionals. The Publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which photocopying permission is specifically granted in a footnote. This license is limited to you, the individ- ual purchaser, for use with your own clients and patients. It does not extend to additional clinicians or practice settings, nor does purchase by an institu- tion constitute a site license. This license does not grant the right to reproduce these materials for resale, redistribution, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, and hand- outs or slides for lectures or workshops). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications. Library of Congress Cataloging-in-Publication Data Woolfolk, Robert L. Treating somatization : a cognitive-behavioral approach / by Robert L.
    [Show full text]
  • Personality Disorders: Department of Psychiatry, University of Michigan Health System, Ann Arbor a Measured Response (Dr
    Nicholas Morcos, MD; Roy Morcos, MD, FAAFP Personality disorders: Department of Psychiatry, University of Michigan Health System, Ann Arbor A measured response (Dr. N. Morcos); St. Elizabeth Boardman Hospital, Mercy Health, Ohio (Dr. R. Morcos) Improving your understanding of these disorders will help you identify specific diagnoses, ensure appropriate [email protected]. edu treatment, and reduce frustration during office visits. The authors reported no potential conflict of interest relevant to this article. ersonality disorders (PDs) are common, affecting up PRACTICE to 15% of US adults, and are associated with comorbid RECOMMENDATIONS medical and psychiatric conditions and increased utili- ❯ Maintain a high index of P 1,2 zation of health care resources. Having a basic understand- suspicion for personality ing of these patterns of thinking and behaving can help family disorders (PDs) in patients who appear to be “difficult,” physicians (FPs) identify specific PD diagnoses, ensure appro- and take care to distinguish priate treatment, and reduce the frustration that arises when these diagnoses from primary an individual is viewed as a “difficult patient.” mood, anxiety, and Here we describe the diagnostic features of the disorders psychotic disorders. C in the 3 major clusters of PDs and review an effective approach ❯ Refer patients with PDs for to the management of the most common disorder in each clus- psychotherapy, as it is ter, using a case study patient. considered the mainstay of treatment—particularly for borderline PD. B Defense mechanisms offer clues ❯ Use pharmacotherapy that your patient may have a PD judiciously as an adjunctive Personality is an enduring pattern of inner experience and treatment for PD.
    [Show full text]
  • Investigating Correlations Between Defence Mechanisms and Pathological Personality Characteristics
    rev colomb psiquiat. 2019;48(4):232–243 www.elsevier.es/rcp Artículo original Investigating Correlations Between Defence Mechanisms and Pathological Personality Characteristics Lucas de Francisco Carvalho ∗, Ana Maria Reis, Giselle Pianowski Department of Psicology, Universidade São Francisco, Campinas, São Paulo, Brazil article info abstract Article history: Introduction: The purpose of this study was to investigate the relationship between defence Received 4 October 2017 mechanisms and pathological personality traits. Accepted 10 January 2018 Material and methods: We analysed 320 participants aged from 18 to 64 years (70.6% women, Available online 10 February 2018 87.5% university students) who completed the Dimensional Clinical Personality Inventory (IDCP) and the Defence Style Questionnaire (DSQ-40). We conducted comparisons and cor- Keywords: relations and a regression analysis. Personality disorders Results: The results showed expressive differences (d>1.0) between mature, neurotic and Defence mechanisms immature defence mechanism groups, and it was observed that pathological personality Self-assessment traits are more typical in people who use less mature defence mechanisms (i.e., neurotic and immature), which comprises marked personality profiles for each group, according to the IDCP. We also found correlations between some of the 40 specific mechanisms of the DSQ-40 and the 12 dimensions of pathological personality traits from the IDCP (r ≥ 0.30 to r ≤ 0.43), partially supported by the literature. In addition, we used regression analysis to verify the potential of the IDCP dimension clusters (related to personality disorders) to predict defence mechanisms, revealing some minimally expressive predictive values (between 20% and 35%). Discussion: The results indicate that those who tend to use immature defence mechanisms are also those most likely to present pathological personality traits.
    [Show full text]
  • Defense Mechanisms.Pdf
    Defense Mechanisms According to Sigmund Freud, who originated the Defense Mechanism theory, Defense Mechanisms occur when our ego cannot meet the demands of reality. They are psychological strategies brought into play by the unconscious mind to manipulate, deny or distort reality so as to maintain a socially acceptable self-image. Healthy people normally use these mechanisms throughout life. it becomes pathological only when its persistent use leads to maladaptive behavior such that the physical and/or mental health of the individual is adversely affected. The purpose of ego defense mechanisms is to protect the mind/self/ego from anxiety and/or social sanctions and/or to provide a refuge from a situation with which one cannot currently cope. Defense mechanisms are unconscious coping mechanisms that reduce anxiety generated by threats from unacceptable impulses In 1977, psychologist George Vaillant took Freud’s theory and built upon it by categorizing them, placing Freud’s mechanisms on a continuum related to their psychoanalytical developmental level. Level 1: Pathological Defenses The mechanisms on this level, when predominating, almost always are severely pathological. These six defense’s, in conjunction, permit one to effectively rearrange external experiences to eliminate the need to cope with reality. The pathological users of these mechanisms frequently appear irrational or insane to others. These are the "psychotic" defense’s, common in overt psychosis. However, they are found in dreams and throughout childhood as well. They include: Delusional Projection: Delusions about external reality, usually of a persecutory nature. Conversion: the expression of an intra-psychic conflict as a physical symptom; some examples include blindness, deafness, paralysis, or numbness.
    [Show full text]
  • Self-Destruction and Countertransference Reactions in Adolescent Psychotherapy: a Psychoanalytic Case Report
    Journal of Psychology & Clinical Psychiatry Self-Destruction and Countertransference Reactions in Adolescent Psychotherapy: A Psychoanalytic Case Report Abstract Case Report Self-destruction behaviors in adolescents constitute a serious mental health problem. Several psychoanalysts and psychodynamic theorists have long attempted Volume 1 Issue 3 - 2014 to understand the desire of self-destruction. Suicidal adolescents often elicit strong George Giannakopoulos*, Kalliopi Triantafyllou and Stylianos countertransference reactions from therapists. These reactions fluctuate from the Christogiorgos throughbelief that of therepresentations therapist should and beemotions the perfect produced object by that the will patient relieve in the sufferinganalyst’s mindteenager facilitates to the openlyfurther hostile understanding stance by theof transferencetherapist. The phenomena. awareness andThe working- present Department of Child Psychiatry, University of Athens Medical School, Greece psychoanalytic case report of a suicidal adolescent tries to illustrate some aspects of *Corresponding author: to the diagnostic access and the treatment of adolescents after a suicide attempt. Department of Child Psychiatry, University of Athens these complex reactions. The psychodynamic approaches can contribute significantly Medical School, Aghia Sophia Children’sGeorge Giannakopoulos, Hospital, Keywords Thivon and Papadiamantopoulou 11527 Athens, Greece, Tel: 0030210747381; Fax: 0030210747381; Email: Adolescence; Countertransference; Psychoanalytic psychotherapy; Suicide attempt [email protected]: June 23, 2014 | Published: July 11, 2014 Introduction Self-destruction behaviors in adolescents constitute a serious mental health problem, with approximately 80% of suicidal when the ego is in so really great danger that it feels unable to thoughts and attempts present in adolescents struggling with a overcomerescue function alone, that it sees before itself was as fulfilleddeserted by by the all mother. protective However, forces psychiatric disorder [1,2].
    [Show full text]
  • Defense Mechanisms
    CLINICAL EDUCATION AND INTERVENTIONS FOR DEFENSE STRUCTURES OF CO-OCCURRING POPULATIONS Brian G. Lengfelder LCPC, CAADC, CCJP, SAP, MAC, CSAT, CMAT, ACRPS WHAT CONSTITUTES DEFENSE MECHANISMS • The term ‘defense mechanisms’ was coined over 100 years ago to describe a construct of psychological mechanisms for coping with intrapsychic conflicts. • Defense mechanisms and conflicts are two hypothetical constructs that have remained at the core of psychodynamic approaches to understanding and treating clinical psychopathology. • Defense mechanisms mediate between an individual’s wishes, needs, and affects on the one hand, and both internalized object relations and external reality on the other. Freud, S. The neuro-psychosis of defense, in Strachey, J. (ed.): The Standard Edition of the Complete Psychological Works of Sigmund Freud, London, Hogarth, (original work published 1894), 1962, pp. 43-68. DEFENSE MECHANISMS DEFINED • Mechanisms that mediate the individual’s reaction to emotional conflicts and to external stressors. Some defense mechanisms (e.g., projection, splitting, acting out) are almost invariably maladaptive. Others (e.g., suppression, denial) may be either maladaptive or adaptive, depending on their severity, their inflexibility, and the context in which they occur. 2013, DSM-5 American Psychiatric Association DEFENSE MECHANISMS DEFINED • Defense mechanisms (or coping styles) are automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. Individuals
    [Show full text]
  • The Invisible Revealed: Collusion As an Entry to the Group Unconscious
    The Invisible Revealed: Collusion as an Entry to the Group Unconscious Gianpiero Petriglieri and Jack Denfeld Wood Abstract earlier experience and all-too-familiar “dys- In group consultation, as in therapy, a functional” patterns of behavior. Whichever shared awareness of projective processes is our formal role in a group—as consultant or helpful to both consultant and client. If left member—we inevitably experience the constel- unaware, the flow of material can submerge lation of our unconscious complexes. All of us both. The consultant risks colluding with the can get “hooked” and “lose it” and regress to group by adopting their projections and then previous behaviors. We subsequently feel em- either withdrawing or acting out. When such barrassed or guilty and berate ourselves that we situations are “exposed,” they are usually “should have known” or “should have managed considered to be either professional embar- better” or “should have kept things under con- rassments or evidence of professional incom- trol.” petence. Yet careful investigation of the ex- Behavioral professionals are constantly perience of collusion can lead to a deeper warned by their teachers, supervisors, and col- understanding of the covert and unconscious leagues about the risk of losing their “objec- elements of working with a group. tive” and “unbiased” perspective—of “going ______ native,” of having their “buttons pushed” and being “hooked” into their clients’ games, of Had we been a bit braver, we would have “falling out of role,” and so on. If this is a risk titled this article “The Importance of Collusion: when working with an individual client, it is Working with the Impulse to Withdraw and Act even more of a risk when working with a Out in Group Consultation.” Our aim is to ex- group, the gravity of whose psychological pull plore how consultants who find themselves col- is considerably stronger and much more multi- luding with their groups—and deploying de- dimensional.
    [Show full text]
  • Table 5: Defense Mechanisms
    TABLE 5: DEFENSE MECHANISMS NARCISSISTIC DEFENSES IMMATURE DEFENSES NEUROTIC DEFENSES MATURE DEFENSES Denial- Negates sensory data to avoid awareness Acting Out- Acts an unconscious impulse or affect Controlling- Manage or regulate environment Altruism- Experiences vicarious pleasure by of painful aspect of reality. Abolishes external to avoid affect. Acting gives into the impulse rather excessively to avoid anxiety. serving others constructively and instinctually. reality. Used in normal and pathological states. than prohibiting it. Avoids the tension of Reaction formation is benign and constructive. postponing expression. Serving others does not take the place of meeting own needs. Distortion- Reshapes external reality to suit inner Blocking- Inhibits thinking temporarily. May Displacement- Shifts an emotion or drive from Anticipation- Anticipates, plans for future inner needs. Beliefs, hallucinations, delusions. Sustains include affects and impulses. Resembles one idea or object to another. Permits symbolic discomfort that is goal directed. Careful planning or feelings of superiority, entitlement. repression, except tension felt. representation of less distress. worrying and premature but realistic affective anticipation of dire and potentially dreadful outcomes. Primitive Idealization- Endows either “all good, Hypocondriasis- Transforms bereavement, Dissociation- Drastically modifies personal Asceticism- Eliminates pleasurable effects of omnipotent” or “all bad,” inflated external objects loneliness, aggressive impulses into self-reproach, identity or character to avoid emotional distress, experiences. Uses morals to assign values to with great power pain, somatic illness. Avoids responsibility, including fugue states, hysterical conversion, DID, specific pleasures. Derives gratification from circumvents guilt. Affliction due to ego-alien nature drug highs, religious joy. renunciation of all consciously-perceived base of introjects. pleasures. Projection- Perceives and reacts to inner qualities Identification- Crucial to ego development.
    [Show full text]
  • Working with Parents of Children Who Have Been Sexually Assaulted the ADVOCATE’S GUIDE: Working with Parents of Children Who Have Been Sexually Assaulted
    The Advocate’s Guide: Working With Parents Of Children Who Have Been Sexually Assaulted THE ADVOCATE’S GUIDE: Working With Parents Of Children Who Have Been Sexually Assaulted TABLE OF CONTENTS PREFACE: Using this guide Page 2 PART ONE: Connecting - Communicating - Clarifying Page 4 PART TWO: Communicating Key Concepts to Parents Page 24 PART THREE: Creating Bridges: Interfacing with Systems Page 30 PART FOUR: Complicating Issues Page 45 PART FIVE: Helping Parents Cope Page 49 PART SIX: Frequently Asked Questions Page 55 PART SEVEN: Acknowledgements Page 61 PART EIGHT: References Page 63 APPENDIX: Trauma-Informed Parenting (TIP) sheets Page 65 Suggested citation: Yamamoto, D. (2015). The advocate’s guide: Working with parents of children who have been sexually assaulted. Enola, PA: National Sexual Violence Resource Center. The content of this publication may be reprinted with the following acknowledgement: This material was reprinted, with permission, from the National Sexual Violence Resource Center’s publication entitled The advocate’s guide: Working with parents of children who have been sexually assaulted. Also available online at the Lifespan webpage of National Sexual Violence Resource Center website: http://www.nsvrc.org/projects/lifespan/sexual-violence-against-children The Advocate’s Guide: Working With Parents Of Children Who Have Been Sexually Assaulted 1 Using this Guide This guide is designed for sexual assault program advocates working with non-offending parents and/or caregivers of children who have experienced sexual assault. The suggestions and strategies are intended for use with children under the age of 13. Additionally, the following terms and their definitions will apply: The primary client: The child who was this document, the terms “victim” and victimized is the primary client.
    [Show full text]
  • DBT with Debbie Barrett & Robin Sansing 10/3/2019 UNC-CH
    DBT with Debbie Barrett & Robin Sansing 10/3/2019 UNC SCHOOL OF SOCIAL WORK CLINICAL INSTITUTE SERIES Day 1 Agenda Dialectical Behavioral 9:00 Welcome & Housekeeping Therapy (DBT) 9:10 I. DBT: Introduction 10:15 Break DAY 1 10:30 II. Nuts and bolts: How DBT works Deborah Barrett, PhD, LCSW 12:00 LUNCH & 1:00 III. DBT in action 2:30 Break Robin Sansing, MSW, LCSW 2:45 IV. Strategies during therapy October 3 & 4, 2019 4:30 END University of North Carolina at Chapel Hill Dialectical Behavioral Therapy Developed by Marsha Linehan Began as intervention for I. Introduction chronically suicidal women To history, theory, and practice Combines behavioral principals with Buddhist practice of “mindfulness” (1993) History Formative history Late 1970s, Marsha Linehan attempted to apply DBT created in response to problems Linehan noted: cognitive behavioral therapy (CBT) to adult women with chronic suicidal attempts and para- Reinforcement – little incentive to broach difficult topics suicidal behaviors. EXAMPLE: therapists back off when clients express anger or mention self-harm; clients respond with warmth to topic change Dilemma: How can therapist teach adaptive behaviors when client is in continuous crisis? Invalidating nature of “change” therapies UNC-CH School of Social Work Clinical Institute 1 DBT with Debbie Barrett & Robin Sansing 10/3/2019 Balance Core Strategies DBT Approach 1. CBT 2. plus: Acceptance strategies (validation & Change Acceptance mindfulness) Problem Solving 3. plus: Dialectical worldview and strategies Validation - both/and
    [Show full text]
  • Understanding and Treating the Sexually Acting out Child
    Understanding and Treating the Sexually Acting Out Child By: Mistie Barnes, M.Ed., LPC-S, RPT-S Email: [email protected] Juliet Fortino, MC, LPC, RPT-S Email: [email protected] Recently, a parent asked, “Is it normal for two-year-olds to touch themselves or does that mean they’ve been sexually abused?” This is not an uncommon question from concerned caregivers, especially when children begin to exhibit sexual behaviors. However, to answer this question, it is important to understand child sexual development and the differences in sexual reactivity and sexual offense, which are often confused. Like most trauma responses, sexual reactivity is a normal response to an extreme event–the event of being sexually abused (Dominguez, Nelke, & Perry, 2006). Many clinicians who work with children who have been sexually abused understand that sexual reactivity can be a part of the process of sexual abuse. However, for those that do not work with these children, sexualized behaviors can be confusing and worrisome. Given this, it is important to be able to distinguish between healthy sexual development in children and the sexual behavior of children who have been sexually abused. Origins of Sexual Reactivity According to the National Children’s Alliance (2009), between January and June of 2009, 129,548 children were served at Child Advocacy Centers in the United States. Of these children, 94,689 were served in response to sexual abuse. Children experiencing sexual abuse may experience a number of short- and long-term symptoms, including enuresis and encopresis (Homeyer & Landreth, 1998). Children who have been sexually abused may also experience a change in appetite, nightmares, aggression, over compliance, age inappropriate knowledge of sexual behaviors, fear of previously unfeared persons (Childhelp, n.d.; Levine & Kline, 2007), problems maintaining peer relationships, genital discomfort, dissociation, regressive behavior, mood swings, and sexually transmitted diseases (Levine & Kline, 2007).
    [Show full text]
  • Do Spinal Cord-Injured Individuals with Stronger Sense of Coherence Use Different Psychological Defense Styles?
    Spinal Cord (2016) 54, 843–848 & 2016 International Spinal Cord Society All rights reserved 1362-4393/16 www.nature.com/sc ORIGINAL ARTICLE Do spinal cord-injured individuals with stronger sense of coherence use different psychological defense styles? J Shakeri1, M Yazdanshenas Ghazwin2, E Rakizadeh3, A Moshari4, H Sharbatdaralaei5, S Latifi2 and SAH Tavakoli6 Objectives: Although the importance of sense of coherence (SOC) and psychological defense mechanisms (PDMs) in the process of coping has been demonstrated, it has not yet been clarified whether individuals with stronger SOC use specificPDMs. Study design: Cross-sectional. Setting: Iran. Methods: Demographic and injury-related variables including injury level, time since injury, American Spinal Cord Association (ASIA) Scale and Spinal cord independence measure-III were collected among individuals with spinal cord injury (SCI). SOC was assessed by the Short-form Sense of Coherence Scale. PDMs were identified using 40-version of the Defense Style Questionnaire. Results: Neurotic defense style was the most commonly used style especially. The overall most commonly used PDM was ‘rationalization’, which was used by 95%. Individuals with stronger SOC used more mature style (P = 0.001, r = 0.52), particularly ‘humor’ and ‘suppression’ mechanisms (Po0.0001 and 0.024, respectively). There was a negative correlation between stronger SOC and the use of immature defenses including passive aggression (P = 0.001, r = − 0.51), acting out (P = 0.001, r = − 0.48), isolation (P = 0.009, r = − 0.50), autistic fantasy (P = 0.010, r = − 0.30) and somatization (Po0.0001, r = − 0.62). Married individuals had significantly stronger SOC (P = 0.01).
    [Show full text]