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PSYC*3390 Ch 8.doc

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University of Guelph
PSYC 3390
Mary Manson

Monday, October 29, 2012 Chapter 8: Somatoform and Dissociative Disorders - involve more complex and puzzling patterns of symptoms Somatoform Disorders - a group of conditions that involve physical symptoms and complaints suggesting the presence of a medical condition but without any evidence of of physical pathology to account for them, the person is preoccupied with some aspect of her or his health of appearance to the extent that they show significant impairments in functioning Dissociative Disorders - involve disruptions in a person’s normally integrated functions of consciousness, memory, identity, or perception, included here are some of the more dramatic phenomena in the entire domain of psychopathology: people who cannot recall who they are or where they may have come from, and people who have 2 or more dis- tinct identities or personality states that alternately take control of the individual’s behav- iour Dissociation - the human mind’s capacity to engage in complex mental activity in chan- nels split off from or independent of conscious awareness - somatoform and dissociative disorders were once included with anxiety disorders un- der the general rubric neuroses, but when the focus moved to grouping disorders to- gether on the basis of overt symptomatology, the disorders became separate Somatoform Disorders - soma means body, and somatoform disorders involve patterns in which individuals complain of bodily symptoms or defects that suggest the presence of medical problems, but for which no organic basis can be found that satisfactorily explains the symptoms e.g. paralysis or pain - the affected patients have no control over their symptoms and are not intentionally fak- ing symptoms or attempting to deceive others - they genuinely and sometimes passionately believe something is terribly wrong - although it is thought to be characteristic of particular ethnocultural groups, re- searchers have found that it is common in all cultural groups and societies - differences among groups may reflect cultural styles of expressing distress, which are influenced not only by cultural beliefs and practices but also by the nature of the culture’- s healthcare system Hypochondriasis Monday, October 29, 2012 - preoccupied either with fears of contracting a serious disease or with the idea that they actually have such a disease even though they do not - their preoccupations are based on the misinterpretation of one or more bodily changes, sensations or symptoms of minor ailment - the person is not reassured by the results of a medical evaluations, the fear of having a disease persists despite medical reassurance - sometimes they are disappointed when no physical problem is found - the condition must persist for at least 6 months - usually first go to a medical doctor with their physical complaints - they often shop for additional doctors, hoping one might discover what their problem is - they generally resist the idea that their problem is a psychological one that might best be treated by a psychologists or psychiatrist - may be the most commonly seen somatoform disorder, with a prevalence in general medical practice estimated at between 2 and 7% - occurs equally often in men and women and can start at any age although early adult- hood is the most common age of onset - once it develops, it tends to be chronic if left untreated, although the severity may wax and wane over time - individuals with hypochondriasis often also suffer from mood disorders, panic disorder, and/or other somatoform disorders Major Characteristics - often anxious and highly preoccupied with bodily functions (heart beats, bowl move- ments, small sores or occasional coughs) or with vague and ambiguous physical sensa- tions such as “tired heart” or “aching veins” - they attribute these symptoms to a suspected disease and often have intrusive thoughts about it - the diagnoses they make for themselves range from tuberculosis to cancer, exotic in- fections, AIDS, and numerous other diseases - they are not malingering, which is defined as consciously faking symptoms to achieve specific goals - they tend to doubt the soundness of their doctor’s conclusions and recommendations, so doctor-patient relationships are often marked by conflict and hostility Theoretical Perspectives on Causal Factors - cognitive-behavioural views of hypochondriasis are perhaps most widely accepts and have as a central tenet that it is a disorder of cognition and perception Monday, October 29, 2012 - misinterpretations of bodily sensations are currently a defining feature, but in the cog- nitive-behavioural view, these misinterpretations also play a causal role - it is believed that an individual’s past experiences with illnesses lead to the develop- ment of a set of dysfunctional assumptions about symptoms and diseases - seem to focus excessive attention on symptoms, with an attentional bias for illness-re- lated information - they perceive their symptoms as more dangerous than they really are and judge a par- ticular disease to be more likely or dangerous than it really is - once they have misinterpreted a symptom, they tend to look for confirming evidence and to discount evidence that they are in good health - they also perceive their probability of being able to cope with the illness as extremely low and see themselves as weak and unable to tolerate physical effort or exercise - this tends to create a vicious cycle in which their anxiety about illness and symptoms results in physiological symptoms of anxiety, which provides further fuel for their convic- tions that they are ill - hypochondriacal patients reported much childhood sickness and missing of school, and have an excessive amount of illness in their families while growing up, which may lead to strong memories of being sick or in pain, and perhaps of having observed some of the secondary benefits that sick people sometimes reap Treatment of Hypochondriasis - cognitive-behavioural treatment have found to be very effective - the cognitive components focus on assessing the patient’s beliefs about illness and modifying misinterpretations of bodily sensations - the behavioural techniques include having patients induce innocuous symptoms by in- tentionally focusing on parts of their body so that they can learn that selective percep- tion of bodily sensations plays a major role in their symptoms - summits they are also directed to engage in response prevention by not checking their body as they usually do and by stopping their constant seeking of reassurance - the treatment (6-16 sessions) produced large changes in the hypochondriacal symp- toms and beliefs as well as in levels of anxiety and depression - certain antidepressants may be effective Somatization Disorder - many different complaints of physical ailments, over at least several years beginning before age 30, that are not adequately explained by independent findings of physical ill- ness or injury and that lead to medical treatment or to significant life impairment Monday, October 29, 2012 - there are 4 other symptom criteria that must be met at some time during the course of the disorder before a diagnosis can be made - the diagnostician need not be convinced that these claimed illnesses actually exist, the mere reporting of them is sufficient 1. Four pain symptoms - must report a history of pain experienced with respect to at least 4 different sites or functions 2. Two gastrointestinal symptoms - a history of at least 2 symptoms, other than pain, pertaining to the gastrointestinal system, such as nausea, bloating, diarrhea, or vomiting when not pregnant 3. One sexual symptom - at least one reproductive system symptom other than pain e.g. sexual indifference or dysfunction, menstrual irregularity, or vomiting during pregnancy 4. One Pseudoneurological symptom - a history of at least one symptom, not limited to pain, suggestive of a neurological condition, e.g. loss of sensation, involuntary muscle contraction in a hand - hypochondriacs are different because they are convinced they have an organic dis- ease and usually only have one or a few primary symptoms Demographics, Comorbidity, and Course of Illness - formerly called Briquet’s syndrome, has not been extensively researched - usually begins in adolescence and believed to be about 3-10x more common among women than men - tends to occur more in lower socioeconomic classes - the lifetime prevalence estimate to be between 0.2 and 2% in women and 0.2% in men - commonly occurs with several other disorders including major depression, panic disor- der, phobic disorders, and generalized anxiety disorder - generally been considered to be a relatively chronic condition with a poor prognosis, but some recent studies have begun to challenge this view Causal Factors in Somatization Disorder - there is evidence that it runs in families and that there is a familial linkage between an- tisocial personality disorder in men - one possibility is that the 2 disorders may be linked through a common trait of impul- sivity, but the nature of this relationship is not yet understood - causal factors probably include an interaction of personality, cognitive, and learning variables - people high on neuroticism who come from certain kinds of family backgrounds may develop a tendency to misinterpret their bodily sensations as threatening or disabling Monday, October 29, 2012 - especially likely in families where a child is frequently exposed to models complaining of pain and learns that complaining about symptoms can lead to sympathy and attention (social reinforcement) and even to avoid responsibilities (a secondary gain) - people selectively attend to bodily sensations and tend to see bodily sensations as so- matic symptoms - believing themselves to be weak, they may avoid activities that require much exertion including physical activity, ironically, lowered physical activity can lead to being physical- ly unfit, which can increase bodily sensations about which to catastrophes - selectively attending to bodily sensations may actually increase their intensity - patients also have elevated levels of cortisol and did not show normal habituation to psychological stressors Treatment of Somatization Disorder - long been considered extremely difficult to treat - cognitive-behavioural therapy may be quite helpful when combined with appropriate medical management - effective treatment involves identifying one physician who will integrate the patient’s care by seeing the patient at regular visits and providing physical exams focused on new complaints - at the same time, the physician avoids unnecessary diagnostic testing and makes min- imal use of medications or other therapies - this combined with cognitive-behavioural therapy, which focuses on promoting appro- priate behaviour such as better coping and personal adjustment, and discouraging inap- propriate behaviour such as illness behaviour - focus is on changing the way the patient thinks about bodily sensations and reducing any secondary gain the patients may receive from physicians and family Pain Disorder - resemble pain symptoms seen in somatization disorder, but other kind of symptoms are not present, it is characterized by the experience of persistent and severe pain in one or more areas of the body - although a medical condition may contribute to the pain, psychological factors must be judged to play an important role - important to remember that the pain that is experienced is very real and can hurt as much as pain with purely medical causes - also important that pain is always, in part, a subjective experience that is private and cannot be objectively identified by others Monday, October 29, 2012 - there are 2 coded subtypes: (1) pain disorder associated with psychological factors and (2) pain disorder associated with both psychological factors and a general medical condition - in either case, the pain may be acute (less than 6 months) or chronic (over 6 months) - prevalence is unknown but definitely quite common among patients at pain clinics - diagnosed more frequently in women than in mean and is frequently comorbid with anxiety and/or mood disorders, which may occur first or may arise later as a conse- quence of the pain disorder - often unable to work or to perform some other usual daily activities - their inactivity and social isolation may lead to depression and tao loss of physical strength and endurance, leading to a vicious cycle - the behavioural component of pain is quite malleable in the sense that it can increase when it is reinforced by attention, sympathy, or avoidance of unwanted activities Treatment of Pain Disorder - less complex and multifaceted than somatization disorder so usually easier to treat - cognitive-behavioural techniques have been widely used in the treatment of both physi- cal and psychogenic pain syndromes - treatment programs generally include relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of “no-pain” behaviours - patients tend to show substantial reductions in disability and distress, although changes in the intensity of their pain tend to be smaller in magnitude - antidepressant medications have been shown to reduce pain intensity Conversion Disorder - involves a pattern in which symptoms or deficits affective sensory or voluntary motor functions lead one to think a patient has a medical or neurological condition - upon medical examination, it becomes apparent that the pattern of symptoms or deficits cannot be fully explained by any known medical condition - typical examples include partial paralysis, blindness, deafness, and pseudoseizures - psychological factors must be judged to play an important role in the symptoms or deficits, because the symptoms usually either start or are exacerbated by preceding emotional or interpersonal conflicts or stressors - the person must not be intentionally producing or faking the symptoms - show very little anxiety and fear that would be expected Monday, October 29, 2012 - this seeming lack of concern in the way the patient describes what is wrong was thought for a long time to be an important diagnostic criterion - research shows that it actually occurs in only about 30-50% of patients - it is now thought that most patients are actually quite anxious and concerned - no more likely than people with real physical disorders to display lack of concern - it is one of the most intriguing and baffling patterns in psychopathology - contemporary research has been very sparse - Freud believed that anxiety threatens to become conscious, so it is unconsciously con- verted into a bodily disturbance, thereby allowing the person to avoid having to deal with the conflict Precipitating Circumstances, Escape, and Secondary Gains - although Freud’s theory is no longer accepted outside psychodynamics circles, many of Freud’s astute clinical observations about primary and secondary gain are still incor- porated into physical contemporary views of conversion disorder - the symptoms are usually seen as serving the rather obvious function of providing a plausible excuse, enabling an individual to escape or to avoid an intolerably stressful sit- uation without having to take responsibility for doing so - typically, it is thought that the person first experiences a traumatic event that motivates the desire to escape the unpleasant situation - the primary gain for conversion symptoms is continued escape or avoidance of a stressful situation, because that is all unconscious, the symptoms go away only if the stressful situation has been removed or resolved - secondary gain originally referred to advantages of the symptoms, refers to any exter- nal circumstance, such as attention from a loved one or financial compensation Decreasing Prevalence and Demographic Characteristics - once relatively common in civilian and especially military life - most frequently diagnosed psychiatric syndrome among soldiers in WWI & II - typically occurred under highly stressful combat conditions and involved men who would ordinarily be considered stable - conversion symptoms enabled a soldier to avoid an anxiety-arousing combat situation - today, conversion disorder constitute only 1-3% of all disorders referred for mental health treatment - the prevalence is unknown but highest estimates are around 0.005% - decreasing prevalence seems to be closely related to our growing sophistication about medical and psychological disorders, it apparently loses its defensive function if it can be readily shown to lack an organic basis Monday, October 29, 2012 - more likely to occur in rural people from lower socioeconomic circles who are medically unsophisticated - occurs 2-10x more often in women than in men, can develop at any age but most com- monly occurs between early adolescence and early adulthood - generally has a rapid onset after a significant stressor and often resolves within 2 weeks if the stressor is removed, although it commonly recurs - like most other somatoform disorders, it frequently occurs along with other disorders, major depression, anxiety disorders, and somatization and dissociative disorders Range of Conversion Disorder Symptoms - as diverse as for physically based ailments - useful to think in terms of 4 categories of symptoms: (1) sensory, (2) motor, (3) seizures, and (4) mixed presentation from the first 3 categories Sensory Symptoms or Deficits - can involve almost any sensory modality and can often be diagnosed, because symp- toms in the affected area are inconsistent with how known anatomical sensory pathways operate - sensory symptoms or deficits are most often in the visual system (especially blindness and tunnel vision), in the auditory system (especially deafness), or in the sensitivity to feeling (especially the anesthesias - losing feeling in a part of their body) - one of the most common is glove anesthesia, where a person cannot feel anything on the hand in the area where gloves are worn - with conversion blindness, the person reports that he or she cannot see and yet can often navigate about a room without bumping into furniture - with conversion deafness, the person reports not being able to hear yet orients appro- priately upon “hearing” his or her own name - can the person actually not see or hear, or is the sensory information received but screen from consciousness - evidence supports the idea that the sensory input is registered but that it is somehow screened from explicit conscious recognition Motor Symptoms or Deficits - motor conversion reactions cover a wide range of symptoms - e.g. conversion paralysis is usually confined to a single limb, such as an arm or a leg, and the loss of function is usually selective for certain functions - person may not be able to write but may be able to use the same muscles for scratch- ing or may not be able to walk most of the time but may be able to walk in an emergen- cy such as a fire Monday, October 29, 2012 - the most common speech-related conversion disturbance is aphonia, in which a per- son is able to talk only in a whisper, although he or she can usually cough in a normal manner Seizures - involve pseudoseizures, which resemble epileptic seizures in some ways but can be fairly well differentiated via modern medical technology - they do not show any EEG abnormalities and do not show confusion and loss of mem- ber - often show excessive thrashing about and writhing not seen with true seizures, and they rarely injure themselves in falls or lose control over their bowels or bladder Important Issues in Diagnosing Conversions Disorder - because the symptoms can stimulate a variety of medical conditions, accurate diagno- sis can be extremely difficult - it is crucial that a person with suspected conversion symptoms receive a thorough medical and neurological examination - several criteria are also commonly used for distinguishing between conversions disor- ders and true organic disturbances: 1. The frequent failure of the dysfunction to conform clearly to the symptoms of the par- ticular disease or disorder simulated 2. The selective nature of the dysfunction, e.g. in conversion blindness, the affected indi- vidual does not usually bump into people 3. Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms can usually be removed, shifted, or reinduced at the suggestion of the therapist Distinguishing Conversion from Malingering and From Factitious Disorder - sometimes, p
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