Chapter 7.doc

CHAPTER 7 – SOMATOFORM AND DISSOCIATIVE DISORDERS: Somatoform and dissociative disorders are related to anxiety disorders in that, in early versions of the DSM, all these disorders were subsumed under the heading of neuroses because anxiety was considered the predominant underlying factor in each case. somatoform disorder: the individual complains of bodily symptoms that suggest a physical defect or dysfunction – sometimes rather dramatic in nature – but for which no physiological basis can be found. dissociative disorder: the individual experiences disruptions of consciousness, memory and identity. The onset of both classes of disorders is assumed by many to be related to some stressful experience and the two classes sometimes co-occur. SOMATOFORM DISORDERS: Psychological problems take a physical form, no known physiological explanation and are not under voluntary control. The bodily symptoms of these disorders fall typically into two groups: (a) One group of symptoms reflects arousal in the autonomic nervous system and is accompanied by palpable distress in the form of anxiety and depression. (b) The second group of symptoms reflects thoughts and intentions that are not consciously recognized. (SEE TABLE 7.1, page 194). Argument that somatoform disorders should be removed from the pending DSM-V has seven concerns: • The terminology of the somatoform category is often unacceptable to patients • The distinction between symptoms that are disease-based vs, those that are psychogenic may be more apparent than real • There is great heterogeneity among the disorders – the only common link is physical illness that is not attributable to an organic cause • Somatoform disorders are incompatible with other cultures • There is ambiguity in the stated exclusion criteria for the disorders • The subcategories have often failed to achieve accepted standards of reliability. • Somatoform disorders lack clearly defined thresholds in terms of the symptoms needed for a diagnosis. Pain disorder: the person experiences pain that causes significant distress and impairment; psychological factors are viewed as playing an important role in the onset, maintenance, and severity of the pain. The patient may be unable to work and may become dependent on painkillers or tranquilizers. - The pain may have a temporal relation to some conflict or stress, or it may allow the individual to avoid some unpleasant activity and to secure attention and sympathy not otherwise available. - Accurate diagnosis is difficult because the subjective experience of pain is always a psychologically influenced phenomenon. Body dysmorphic disorder (BDB): a person is preoccupied with an imagined or exaggerated defect in appearance, frequently in the face – eg; facial wrinkles, excess facial hair, or the shape or size of the nose. - Women tend also to focus on the skin, hips, breasts and legs, whereas men are more inclined to believe they are too short, that their penises are too small, or that they have too much body hair. - Occurs mostly among women, typically begins in late adolescence, and is frequently comorbid with depression and social phobia, eating disorder and thoughts of suicide. - BDB is chronic. Preoccupation with imagined defects in physical appearance may not be a disorder itself, but a symptom that can occur in several disorders. Hypochondriasis: is a somatoform disorder in which individuals are preoccupied with persistent fears of having a serious disease, despite medical reassurance to the contrary. - Patients are frequent consumers of medical services and are likely to have mood or anxiety disorder. - Is evident in ~5% of the general population and is about as common as other psychiatric disorders. - Not well differentiated from somatisation disorder. - Focus is more on health anxiety rather than hypochondriasis per se. - Health anxiety: health related fears and beliefs, based on interpretations, or perhaps more often, misinterpretations, of bodily signs and symptoms as being indicative of serious illness. - Whereas hypochondriacs have a fear of having an illness, an illness phobia is a fear of contracting an illness. - The Illness Attidutes Scale (IAS) is one self-report measure that is used commonly by researchers to assess heath anxiety. Consists reliably of four factors: (1) worry about illness and pain (i.e. illness fears) (2) disease conviction (i.e. illness beliefs) (3) health habits (i.e. safety-seeking behaviours) (4) symptom interference with lifestyle (i.e. disruptive effects - Health anxiety is mostly learned. - Cognitive factors are featured in the model of health anxiety outlined by Salkovskis and Warwick. This model has four contributing factors: • (1) a critical precipitating incident • (2) a previous experience of illness and related medical factors • (3) the presence of inflexible negative cognitive assumptions (i.e. believing strongly that unexplained bodily changes are always a sign of serious illness • (4) the severity of anxiety. The severity of anxiety is a function of two factors that will increase anxiety and two that will decrease it. o Health anxiety will increase multiplicatively as a function of related increases in (1) perceived likelihood or probability of illness and (2) the perceived presence of rescue factors (i.e the availability and perceived effectiveness of medical help). CONVERSION DISORDER In conversion disorder, physiologically normal people experience sensory or motor symptoms, such as a sudden loss of vision or paralysis, suggesting an illness related to neurological damage of some sort, although the body organs and nervous system are found to be fine. - Sufferers may experience paralysis of arms or legs; seizures and coordination disturbances; a sensation of prickling, tingling, or creeping on the skin; insensitivity to pain; or the loss or impairment of sensations, called anaesthesias. - Vision may be severely impaired, the person may become partially or completely blind or have tunnel vision. - Aphonia, loss of the voice and all but whispered speech and anosmia, loss or impairment of the sense of smell, are other conversion disorders. - Conversion symptoms appear suddenly in stressful situations, allowing the individual to avoid some activity or responsibility or to receive badly wanted attention. - Term conversion derived originally from Freud, who thought that the energy of a repressed instinct was diverted into sensory-motor channels and blocked functioning. Thus, anxiety and psychological conflict were believed to be converted into physical symptoms. - Prevalence or conversion disorder is less than 1%, and more women than men are given the diagnosis. - Co-morbid with other axis 1 diagnosis, such as depression and substance abuse, and with personality disorders, notably borderline and histrionic personality disorders. Hysteria: the term originally used to describe what are now known as conversion disorders, has a long history, dating back to the earliest writings on abnormal behaviour.  It is important to distinguish a conversion paralysis or sensory dysfunction from similar problems that have a neurological basis. (i.e. glove anaesthesia a rare syndrome in which the individual experiences little or no sensation in the part of the hand that would be covered by a glove. - Carpal tunnel syndrome: can produce symptoms similar to those of glove anaesthesia. Nerves in the wrist run through a tunnel formed by the wrist bones and membranes. The tunnel can become swollen and may pinch the nerves, leading to tingling, numbness, and pain in the hand. BOX - MARLINGERING AND FACTITIOUS DISORDER: o Malingering: an individual fakes an incapacity in order to avoid a responsibility such as work or military duty or to achieve some goal such as being awarded a large insurance settlement. o in trying to discriminate conversion reactions from malingering, one aspect of behaviour that can help is la belle indifference, characterized by a relative lack of concern or a blasé attitude toward the symptoms. Patients with conversion disorder sometimes demonstrate this behaviour, they also appear willing and eager to talk endlessly and dramatically about their symptoms. In contrast malingerers are likely to be more guarded and cautious, perhaps because they consider interviews a challenge or threat to the success of the lie. o Munchausen Syndrome; making yourself ill purposely, or when a mother purposely makes her child ill to take care of them and feel like a good mother. SOMATIZATION DISORDER: Somatisation disorder: recurrent, multiple somatic complaints, with no apparent physical cause, for which medical attention is sought. To meet diagnostic criteria, the person must have: (1) four pain symptoms in different locations, (2) two gastrointestinal symptoms (i.e. diarrhea, nausea), (3) one sexual symptom other than pain (i.e. indifference to sex, erectile dysfunction...) and (4) one pseudo- neurological symptom (i.e those of conversion disorder). • These symptoms usually cause impairment, particularly regarding work. The specific symptoms of the disorder may vary across cultures. • The disorder may be more frequent in cultures that de-emphasize the overt display of emotion. • Somatisation disorder and conversion disorder share many symptoms, and both diagnoses may apply to the same patient. • It may not be as stable as the DSM implies; in one study, only one third of patients with somatisation disorder still met diagnostic criteria when reassessed 12 months later. • Somatisation disorder also seems to run in families; it is fund in about 20% of the first-degree relatives of index cases. ETIOLOGY OF SOMATOFORM DISORDER: much of the theorizing has been directed solely toward understanding hysteria as originally conceptualized by Freud. Consequently it has focused on explanations of conversion disorder. Etiology of Somatisation Disorder: It has been proposed that patients with somatisation disorder are more sensitive to physical sensations, over-attend to them, or interpret them catastrophically. Using methods such as the Stroop Test, it has been found that somatoform patients had a memory bias for physical threat words. Patients have high levels of cortisol, an indication that they are under stress. Perhaps the extreme tension of an individual localises in stomach muscles, resulting in feelings of nausea or vomiting. Once normal functioning is disrupted, the maladaptive pattern may strengthen because of the attention it receives or the excuses it provides. Attributing poor performance to illness is psychologically less threatening than attributing it to some personal failing. Psychoanalytic Theory of Conversion Disorder: Breuer and Freud proposed that a conversion disorder is caused when a person experiences an event that creates great emotional arousal but the affect is not expressed and the memory of the event is cut off from conscious experience. The specific conversion symptoms were said to be related causally to the traumatic event that preceded them. In his later writings, Freud hypothesized that conversion disorder in women is rooted in an unresolved Electra complex.  A more contemporary psychodynamic interpretation of one form of conversion disorder, hysterical blindness, is based on experimental studies of hysterical blind people whose behaviour on visual tests showed that they were influenced by the stimuli even though they explicitly denied seeing them. Sackeim et al proposed a two-stage defensive reaction to account for these conflicting findings; (1) perceptual representations of visual stimuli are blocked from awareness, and on this basis people report themselves blind; and (2) information is nonetheless extracted from the perceptual representations. Patients feel that they must deny being privy to this information, they perform more poorly than they would by chance on perceptual tasks. If patients do not need to deny having such information, they perform the task well but still maintain that they are blind. Need to deny is viewed as dependent on personality factors and motivation. It is possible for peo