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Chapter 7

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PSY 606
Thomas Hart

Somatoform Disorders & Dissociative Disorders • Somatoform disorders: the individual complains of bodily symptoms that suggest a physical defect or dysfunction but for which there is no physiological basis • Dissociative disorder: the individual experiences disruptions of consciousness, memory, and identity, as illustrated in the opening case study • The onset of both classes of disorders is typically related to some stressful experience, and the two classes sometimes co-occur Somatoform Disorders • Psychological problems take a physical form • Not under voluntary control • Thought to be linked to anxiety and all psychologically caused • 2 main somatoform disorders: conversion disorder & somatisation disorder • Overall DSM-IV categories of somatoform disorder o Pain disorder: Psychological factors play a significant role in the onset and maintenance of pain o Body dysmorphic disorder: preoccupation with imagined or exaggerated defects in physical appearance o Hypochondriasis: preoccupation with fears of having a serious illness o Conversion disorder: sensory or motor symptoms without any physiological cause o Somatization disorder: recurrent, multiple physical complaints that have not biological basis • Pain disorder o Person experiences pain that causes significant distress & impairment o Psychological factors are viewed as playing an important role in the onset, maintenance, and severity of the pain o Unable to work and may become dependent on pain killers or tranquilizers o Conflict or stress or avoid some unpleasant activity and to secure attention and sympathy not otherwise available o Hard to find where the pain is coming from o People with true physiological pains describe their pain as more localized and with magnitude, while pain disorder patients can’t • Body dysmorphic disorder o Person is preoccupied with an imaged/exaggerated defect in appearance, frequently in the face (facial wrinkles, excess facial hair, shape of nose) o Spend hours each day checking on their defect in the mirror o Leads to frequent consultations with the plastic surgeon o Mostly among women o Typically beings in late adolescence o Frequently comorbid with depression & social phobia o Preoccupation with imaged defects in physical appearance may therefore not be a disorder itself, but a symptom that can occur in several disorders (OCD, delusional disorder) • Hypochondriasis o Individuals are preoccupied with persistent fears of having a serious disease, despite medical reassurance to the contrary o Typically beings in early adulthood and tends to have a chronic course o They make catastrophic interpretations of symptoms o Prevalence of 5% o Not well differentiated from somatisation disorder (long history of complaints) C h a p t e r 7 : S o m a t o f o r m a n d D i s s o c i a t i v e D i s o r d e r s Page 1 o Often co-occurs with anxiety and mood disorders o Health anxiety – health related fears and beliefs o Health anxiety would be present in both hypochondriases and an illness phobia, whereas hypochondriasis is a fear of having an illness, an illness phobia is fear of contracting an illness o Illness Attitude Scale (IAS) : self report measure that is used commonly by researchers to assess health anxiety (used to confirm link between health anxiety and trait neuroticism)  Worry about illness and pain  Disease conviction (illness beliefs)  Health habits  Symptoms interference with lifestyle o Cognitive factors  A critical precipitating incident  A previous experience of illness and related medical factors  The presence of inflexible or negative cognitive assumption are always a sign of serious illness  The severity of anxiety Conversions Disorder • Conversion disorder: Physically 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 • They may experience paralysis of arms or legs; seizures and coordination disturbances; a sensation of prickling, tingling or creeping on the sink, insensitivity to pain; or loss of impairment of sensations (anaesthesias) • They appear suddenly in stressful situations (allowing the individual to avoid some activity or responsibility) or receive badly wanted attention • Freud believed the anxiety and psychological conflict were being converted into physical symptoms • The role of stress plays in the development • Hysteria: used to describe what are known as conversion disorders • Hippocrates thought it limited to women and due to the wandering of the uterus in the body • Symptoms usually develop in adolescents or early adulthood, typically after undergoing life stress • Prevalence is less than 1% • More likely in women than men (but during the war more men did) • Co-morbid with other axis 1 diagnoses, such as depression and substance abuse, and with personality disorders • Glove anaesthesia: a rare syndrome where the person experiences little or no sensation in the part of the hand that would be covered by a glove • 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 (under voluntary control) • La belle indifference: helps to distinguish malingering and conversion disorder o Characterized by relative lack of concern or a blasé attitude toward the symptoms that is out of keeping with their severity and supposedly long-term consequences o Patients with conversion disorders like to talk endlessly about it o Malingerers are more cautious, perhaps because they consider interviews a challenge or threat to the success of the lie o Only 1/3 of people with conversion disorder show la belle indifference • Factitious disorder: patients intentionally produce physical symptoms (sometimes psychological ones) o In contrast to malingering, the symptoms are less obviously linked to a recognized goal C h a p t e r 7 : S o m a t o f o r m a n d D i s s o c i a t i v e D i s o r d e r s Page 1 o For some reason they want to assume the role of a patient o Also may involve a parent creating physical illnesses in a child (Factious disorder by proxy or Munchausen syndrome by proxy) Somatization Disorder • Used to be known as Briquet’s syndrome • Somatization disorder: recurrent, multiple somatic complains, with no apparent physical cause, for which medical attention is sought • To meet diagnostic criteria a person must have o 4 pain syndromes in different location o 2 gastrointestinal symptoms o 1 sexual symptom other than pain o 1 pseudoneurological symptom o More pervasive than in complaints than in hypochondriasis • Usually causes impairment in work and symptoms may vary across cultures • Burning hands or experience of ants crawling under the skin are more frequent • Comorbid with anxiety and mood disorders, substance abuse, and several personality disorders • Prevalence is 0.5% and more frequent in females and patients in medical treatment • Typically beings in early adulthood Etiology of Somatoform Disorders • Directed solely toward understanding hysteria as conceptualized by Freud • It has been proposed that patients with somatisation disorder are more sensitive to physical sensations, over attend to them, or interpret them catastrophically • Behavioural view – various aches, discomforts, and dysfunctions are the manifestation of unrealistic anxiety about bodily systems Psychoanalytic Theory of Conversion Disorder • 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 • Freud also believed that anxiety formed when a child had sexual desire towards their parents was disregarded it is later transformed or converted into physical symptoms • (Sackeim) 2 stage defensive reaction to account for these conflicting findings o Perceptual representations of visual stimuli are blocked from awareness, and on the basis people report themselves blind o Information is nonetheless extracted from the perceptual representations • Contemporary researchers reject the notion of an energy reservoir and repression, holding more simply that we are not aware of everything going on around us or of some of our cognitive processes Behavioural Theory of Conversion Disorder • Ullmann & Krasner • Viewed it as similar to malingering in that the person adopts the symptoms to secure some end • The person attempts to behave according to his or her conception of how person with a disease affecting the motor or sensory abilities would act • Are people capable of such behaviour? Yes people can imitate a illness • Under what conditions would such behaviour occur? o Individual must have some experience with the role to be adopted; he or she may have had similar physical problems or observed t in others o Enactment of a role must be rewarded; positive consequences Social and Cultural Factors of Conversion Disorder • The decrease in this incidence may be attributed to a general relaxing of sexual mores and to greater sophistication of contemporary culture. Which is more tolerant of anxiety than it is of dysfunctions that do not make physiological se Biological Factors in Conversion Disorder C h a p t e r 7 : S o m a t o f o r m a n d D i s s o c i a t i v e D i s o r d e r s Page 1 • Research does not support that genetic factors are important in the development of conversion disorder • There may be some relationship between brain structure and conversion disorder (occurs most likely on the left side of the body than the right) o Thus, more funct
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