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Chapter 8

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Richard B Day

Psych 2AP3: Abnormal Psychology – Major Disorders Chapter 8: Somatoform and Dissociative Disorders Somatoform Disorders - Involves 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 explains the symptoms - Hypochondriasis:  Preoccupied either with fears of contracting a serious disease or with the idea that they actually have such a disease based on the misinterpretation of one or more bodily changes, sensations, or symptoms of minor ailments  Not reassured by the results or a medical evaluation  Condition must persists for at least 6 months  Prevalence between 2 and 7%  Occurs equally in men and women, and can start at almost any age  Tends to be chronic and the severity may wax and wane over time  Often also suffer from mood disorders, panic disorder, and/or other somatoform disorders  Major characteristics:  Often anxious and highly preoccupied with bodily functions or with minor physical abnormalities or with vague and ambiguous sensations  Often have intrusive thoughts about it  Not malingering  Doctor-patient relationships are often marked by conflict and hostility  Theoretical perspectives on causal factors:  Disorder of cognition and perception  Misinterpretations of bodily sensations  Individual’s past experience with illnesses lead to the development of a set of dysfunctional assumptions about symptoms and diseases that may predispose a person to developing hypochondriasis  Perceive their symptoms as more dangerous than they really are and judge a particular disease to be more likely or dangerous than it really is  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  Most of us learn as children that when we are sick special comforts and attention are provided and, we may be excused from a number of responsibilities  Treatment of hypochondriasis:  CBT  Cognitive components focus on assessing the patient’s beliefs about illness and modifying misinterpretations of bodily sensations  Behavioural techniques include having patient induce innocuous symptoms by intentionally focusing on parts of their body so that they can learn that selective perception of bodily sensations plays a major role in their symptoms  Engage in response prevention  Antidepressants - 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 illness or injury and that lead to medical treatment or to significant life impairment  Four pain symptoms: must report a history of pain experienced with respect to at least four different sites or functions  Two gastrointestinal symptoms: must report a history of at least two symptoms, other than pain, pertaining to the gastrointestinal system  One sexual symptom: must report at least one reproductive system symptom other than pain  One pseudoneurological symptom: must report a history of at least one symptom, not limited to pain, suggestive of a neurological condition  Demographics, comorbidity, and course of illness:  Usually begins in adolescence  3-10 times more common among women than men  Tends to occur more in lower socioeconomic classes  Lifetime prevalence between 0.2 and 2% in women and less than 0.2% in men  Co-occurs with major depression, panic disorder, phobic disorders, and generalized anxiety disorder  Causal factors in somatization disorder:  Evidence that it runs in families and that there is a familial linkage between antisocial personality disorder in men and somatization disorder in women  Interaction of personality, cognitive and learning variables  Selectively attend to bodily sensations and tend to see bodily sensations as somatic symptoms  Creation of vicious cycles  Elevated levels of cortisol and did no show normal habituation to psychological stressors  Treatment of somatization disorder:  CBT combined with medical management  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  Cognitive-behavioural therapy focuses on promoting appropriate behaviour and discouraging inappropriate behaviours  Changing the way patients think about bodily sensations and reducing secondary gain  Antidepressants - Panic disorder:  Experience of persistent and severe pain in one or more areas of the body  Two subtypes: pain disorder associated with psychological factors, and pain disorder associated with both psychological factors and a general medical condition  Pain disorder may be acute or chronic  Prevalence is unknown  Diagnosed more commonly in women than in men  Comorbid with anxiety and/or mood disorders  Treatment of pain disorder:  CBT: relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of no-pain behaviours  Antidepressants - Conversion disorder:  Involves a pattern in which symptoms or deficits affecting sensory or voluntary motor functions lead one to think a patient has a medical or neurological condition  Cannot be fully explained by any known medical condition  La belle indifference: show very little anxiety or fear  Precipitating circumstances, escape, and secondary gains:  Physical symptoms are usually seen as serving rather obvious function of providing a plausible excuse, enabling an individual to escape or avoid an intolerably stressful situation without having to take responsibility for doing so  Primary gain for conversion symptoms is continued escape or avoidance of a stressful situation  Secondary gain referring to the advantages that the symptoms bestow beyond the primary gain of neutralizing intrapsychic conflict, has also been retained  Decreasing prevalence and demographic characteristics:  1-3% of all disorders referred for mental health treatment  Prevalence around 0.005 percent  A conversion disorder loses its defensive function if it can be readily shown to lack an organic basis  Most likely to occur in rural people from lower socioeconomic circles who are medically unsophisticated  Occurs two to ten times more in women than in men  Can develop at any age but most commonly occurs between early adolescence and early adulthood  Comorbid with major depression, anxiety disorders, and somatization and dissociative disorders  Range of conversion disorder symptoms:  Four categories of symptoms: sensory, motor, seizures and mixed presentation from the first three categories  Sensory symptoms or deficits:  Can involve any sensory modality and can often be diagnosed because symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate  Most often in the visual or auditory systems, or in the sensitivity to feeling  Implicit perception: evidence supports the idea that the sensory input is registered but that it’s screened from explicit conscious recognition  Motor symptoms or deficits:  Conversion paralysis, aphonia, difficulty swallowing or sensation of a lump in the throat  Seizures:  Pseudoseizures which resemble epileptic seizures in some ways but can usually be fairly well differentiated via modern medical technology  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 conversion disorder:  Through medical and neurological examination  Frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease or disorder simulated  Selective nature of the dysfunction  Under hypnosis or narcosis the symptoms can usually be removed, shifted, or reinduced at the suggestion of the therapist  Distinguishing conversion from malingering and from facticious disorder:  Malingering: intentionally producing or exaggerating physical symptoms and is motivated by external incentives  Facticious disorder: intentionally produces psychological or physical symptoms, but there are no external incentives  Treatment of conversion disorder:  Some patients with motor conversion symptoms have been successfully treated with a behavioural approach in which specific exercises are prescribed and reinforcements are provided when patients show improvements  Hypnosis - Body dysmorphic disorder:  Involves preoccupation with certain aspects of the body  Obsessed with some perceived or imagined flaw or flaws in their appearance causing significant distress and/or impairment in social or occupational functioning  Most people with BDD have compulsive checking behaviours  Avoidance of usual activities  Form of BDD seen mostly in males: muscle dysmoprphia  People with this condition frequently seek reassurance from friends and family about their defects providing temporary relief  Prevalence, gender, and age of onset:  Affects 1-2% of the general population, up to 8% of people with depression  Equal in men and women  Age of onset is usually in adolescence  Commonly also have a depressive diagnosis and often leads to suicide  75% seek nonpsychiatric treatments  Relationship to OCD and eating disorders:  Obsessive-compulsion spectrum disorders: same sets of brain structure are implicated in the two disorders  BDD and anorexia nervosa: body image distortion, excessive concerns and preoccupation about physical appearance, dissatisfaction with one’s body and a distorted image of certain features of one’s body  Why not:  Preval
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