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SOMATOFORM AND DISSOCIATIVE DISORDERS - 1 I. Somatoform Disorders A. Preoccupied with health or body appearance. No identifiable medical condition causing the physical complaints. B. Hypochondriasis refers to physical complaints without a clear cause, and particularly severe anxiety focused on the possibility of having a serious disease. 1. Hypochondriasis shares many features with panic disorder and other anxiety disorders, and rates of comorbidity with such disorders (and mood disorders) are high. 2. The essential problem in hypochondriasis is anxiety, but usually present to physician because of physical complaints. 3. Another important feature of hypochondriasis is that reassurance from numerous doctors that the person is healthy has, at best, only a short-term positive effect. Often such persons will return to the same or other doctors on the assumption that the doctor missed something initially in ruling out medical reasons for the symptoms. This disease conviction has become a core diagnostic feature of hypochondriasis. a. hypochondriasis vs illness phobia b. hypochondriasis - more likely to misinterpret physical symptoms, display higher rates of checking behaviors, have higher levels of trait anxiety, and have a later age of onset than those with illness phobia. 4. Little is known about the prevalence of hypochondriasis in the general population. Approximately 3% of medical patients may meet criteria for hypochondriasis Sex ratio is 50:50 May emerge at any time, with peak periods in adolescence, middle age (40s and 50s) and after age 60. Chronic course. Focus of symptoms varies from culture to culture. SOMATOFORM AND DISSOCIATIVE DISORDERS - 2 5. Etiology: Hypochondriasis is believed to be caused by distorted cognitive or perceptual and emotional factors. For example, persons with hypochondriasis tend to interpret ambiguous stimuli such as minor pain as threatening. These cognitive distortions and increased self- focusing tend to create anxiety and subsequently more physical symptoms in the person, which exacerbates the symptoms. Persons with hypochondriasis also have a restricted concept of health as being totally symptom free. a. Other etiological factors may include genetic vulnerabilities, overreaction to stress, a tendency to view negative life events as unpredictable and uncontrollable, and modeling of illness behaviors by others. b. In addition, persons with hypochondriasis may develop the disorder in the context of a stressful life event, experience a disproportionate incidence of familial disease during childhood, and/or receive substantial attention for illness- related behaviors. 6. Little is known about treating hypochondriasis. Recent studies suggest that cognitive-behavioral treatments, incorporating identifying and challenging illness-related misinterpretations of physical symptoms, showing patients how to voluntarily produce the symptoms, coaching patients to rely less on reassurance, and stress management, seem to be helpful. Little evidence exists to support traditional psychodynamic treatment for hypochondriasis. More recent approaches attempt to offer more substantial and sensitive reassurance than is typical in a physician’s office and with some encouraging results. C. Somatization disorder (known as Briquet's syndrome until 1980), involves an extended history of physical complaints before age 30 and substantial impairment in social or occupational functioning. The textbook presents the case of Linda to illustrate somatization disorder. 1. Persons with somatization disorder are concerned about the symptoms themselves, not what they might mean. Moreover, they show little urgency to respond to, or take action about, their symptoms, despite feeling continually weak and ill. In somatization disorder, the symptoms become a major part of the person’s identity. The DSM-IV requires that the person report 8 symptoms to meet diagnostic criteria, whereas the diagnosis undifferentiated somatoform disorder is reserved for persons who report fewer than 8 symptoms. SOMATOFORM AND DISSOCIATIVE DISORDERS - 3 2. Somatization disorder is rare, and prevalence rates range from 4.4% (in a large city) to 20% of a large sample of primary care patients. Typical age of onset is adolescence. Often unmarried women of lower socioeconomic status. Chronic course. 3. Somatization disorder shares features with hypochondriasis, including a history of family illness or injury during childhood. Data are mixed regarding genetic contributions, although somatization disorder is strongly linked in family studies to antisocial personality disorder (ASPD). a. Some evidence suggests that somatization disorder and ASPD (as well as substance abuse and attention deficit hyperactivity disorder) share a neurobiologically-based disinhibition syndrome. People with these disorders may possess a weak behavioral inhibition system (BIS) that does not control the behavioral activation system (BAS). The BAS is a brain system that underlies impulsivity, thrill-seeking behavior, and excitability, whereas the BIS is involved in sensitivity to threat or danger and avoidance of situations or cues suggesting that threat or danger is imminent. Many behaviors and traits associated with somatization disorder also seem to reflect short-term gain (i.e., active BAS) and insensitivity for long-term problems (i.e., weak BIS). b. Another possibility (not mentioned in book) childhood trauma – physical and/or sexual abuse. c. The major difference between somatization disorder and ASPD, however, may involve level of dependency. Whereas males tend to display aggression and ASPD, females tend to display dependency and little aggression. Therefore, gender socialization may direct a specific biological vulnerability. SOMATOFORM AND DISSOCIATIVE DISORDERS - 4 4. Treatment of somatization disorder is exceedingly difficult, and no treatment exists with demonstrated effectiveness. Treatment of somatization disorder typically involves attempts to reduce the person’s tendency to visit numerous medical specialists according to the "symptom of the week." Use of a gatekeeper physician, one assigned to screen all physical complaints and decide on whether further evaluation is warranted, can be helpful. Additional attention is directed at reducing the supportive consequences of relating to significant others on the basis of physical symptoms. D. Conversion disorders refer to physical malfunctioning without any physical or organic pathology to account for the malfunction, especially in sensory-motor areas. Examples include paralysis, aphonia (i.e., difficulty speaking), mutism, analgesia, seizures, blindness, loss of sense of touch, globus hystericus (i.e., sensation of lump in throat), and astasia-abasia (i.e., weakness in legs and loss of balance). Most conversion symptoms suggest some kind of neurological disease, but can mimic the full range of physical functioning. Conversion disorder is illustrated in the textbook with the case of Eloise. 1. Freud popularized the term "conversion," believing that anxiety from unconscious conflicts is somehow converted into physical symptoms to find expression (i.e., anxiety is displaced onto a more acceptable object, in this case physical problems). SOMATOFORM AND DISSOCIATIVE DISORDERS - 5 2. Several differences exist among those with conversion disorder, actual physical disorder, malingering (i.e., deliberately faking symptoms), factitious disorder (i.e., symptoms are feigned and under voluntary control, but without any obvious reason for doing so aside from assuming the sick role and to gain attention) factitious disorder by proxy (i.e., caregiver making others sick; sometimes referred to as Munchausen’s syndrome by proxy). a. First, as with somatization disorder, conversion disorder is often (but not always) marked by la belle indifference, or a general apathy toward one's symptoms. b. Second, conversion symptoms are usually precipitated by some stressful event. c. Third, those with conversion disorder often function normally but display little insight into this ability. Still, an awareness of sensory and motor information is disturbed. (“Blind” people who can maneuver out of the way of obstacles, but aren’t aware that they can see them. Those who are faking will score below chance on tests of vision.) d. In general, those with conversion disorder are dissociated from sensory-motor awareness, whereas those who malinger or have a factitious disorder attempt to fake this effect (e.g., by faking blindness) and often look worse than blind persons who perform at chance levels on visual discrimination tasks. 3. Unconscious processes are salient features of conversion disorders. It is known that persons with small localized damage to certain parts of their brains can identify objects in their field of vision, but without awareness that they could, in fact, see. The textbook presents the case of Celia to illustrate this concept. SOMATOFORM AND DISSOCIATIVE DISORDERS - 6 4. Conversion disorders are rare, and prevalence estimates in neurological settings range from 1 to 30%, whereas in epilepsy setting the range is between 10 and 20% of cases. Seen primarily in women and typically develop during adolescence or shortly thereafter. More often in less educated, lower socioeconomic status groups where knowledge about disease and medical illness is not well developed. Conversion reactions are not uncommon in soldiers exposed to combat. Symptoms often disappear, but return later in the same or similar form when a new stressor occurs. 5. The Freudian psychodynamic view postulates four basic processes in the development of conversion disorder: a. Experience of a traumatic event, or unacceptable unconscious conflict. b. The person represses the unacceptable conflict and resulting anxiety, thereby making it unconscious. c. Anxiety continues to fester and increase and threatens to emerge into consciousness. The person converts the conflict into physical symptoms, and thereby relieves the pressure of having to deal directly with the conflict. The reduction in anxiety is the primary gain or reinforcing event that maintains the conversion symptom. Primary gain accounts for the la belle indifference as the conversion resolution of the conflict would not be upsetting to the patient. d. Individual receives greatly increased attention and sympathy from loved ones. Freud considered attention/avoidance to represent secondary gain. 6. Little data exists to support Freud’s account; though the role of trauma does have support. A modification of Freud’s approach stipulates that, following the traumatic event, patients develop symptoms purposefully but detach this motivation from consciousness. The behaviors are subsequently maintained by negative reinforcement. (Movie—Tommy) 7. Treatment of conversion disorder is similar to treatment for somatization disorder. A core strategy is to identify and attend to the trauma or stressful life event and to remove sources of secondary gain. The therapist may also work to reduce reinforcing or supportive consequences of the conversion symptoms (i.e., secondary gain). SOMATOFORM AND DISSOCIATIVE DISORDERS - 7 E. Pain disorder refers to a disorder where there may have been initial clear reasons for pain, but where psychological factors play a large role in the persistence of pain. It is difficult to judge cases where the causes were primarily physical vs. psychological. An important feature of pain disorder is that the pain is real and it hurts. The textbook presents the cases of a medical student and a woman with cancer to illustrate pain disorder. F. Persons with body dysmorphic disorder (BDD) (or imagined ugliness) display a preoccupation with some imagined defect in appearance despite reasonably normal appearance. That is, the focus is on physical appearance. Reaction to perceived distortions in facial features is common. These persons are fixated on mirrors, engage in suicidal behavior, display ideas of reference (i.e., thinking that events in the world are somehow related to them and their imagined defect) and avoidance, and experience severe disruption in daily functioning. The condition was previously known as dysmorphophobia (i.e., fear of ugliness). The textbook illustrates BDD with the case of Jim. 1. The predominant focus of attention in adolescence is skin and hair. The disorder is largely influenced by cultural standards of beauty. Examples include skin condition, facial width, slope of nose, and lip, neck, and foot size. 2. Many persons with BDD become fixated on mirrors and frequently check their appearance. Others show a phobic fear and avoidance of mirrors. Suicidal ideation, attempts, and suicide completion are frequent consequences of BDD. 3. Best estimates of the prevalence of BDD are that is it more common that previously thought and that it tends to run a lifelong, chronic course if left untreated. BDD is seen equally in males and females, few marry, and age of onset ranges from early adolescence through the 20s, peaking at age 18 or 19. BDD is not seen frequently in mental health settings as BDD sufferers frequently seek out plastic surgeons. 4. Little is known about the causes or treatment of BDD, including whether BDD runs in families, biological and predisposing vulnerabilities. Obsessive-compulsive disorder tends to co-occur with BDD and both disorders share similar features (e.g., intrusive thoughts, checking). There are two and only two treatments for BDD with any evidence of effectiveness. a. SSRIs, such as clomipramine (Anafranil) and fluvoxamine (Luvox) provide relief for some people; both drugs also work for OCD. b. Cognitive-behavior therapy, specifically exposure and response prevention, has been successful with BDD and of course OCD. SOMATOFORM AND DISSOCIATIVE DISORDERS - 8 5. BDD is big business for plastic surgeons. As many as 25% of persons requesting plastic surgery meet criteria for BDD. Persons with BDD do not benefit from plastic surgery, and preoccupation with imagined ugliness may actually increase following plastic surgery. II. Dissociative Disorders A. Dissociative disorders characterize alterations or detachments in consciousness or identity involving either dissociation or depersonalization. Dissociative disorders include depersonalization disorder, dissociative amnesia, dissociative fugue, dissociative trance disorder, and dissociative identity disorder. Each involves extreme manifestations of normal variants of depersonalization and derealization experiences. 1. Depersonalization involves distortion in perception such that a sense of reality is lost. Symptoms of unreality are characteristic of dissociative disorders because depersonalization is a psychological mechanism whereby one dissociates from reality. 2. Derealization involves losing a sense of the external world (e.g., things may seem to change shape or size; people may appear dead or mechanical). 3. Feelings of depersonalization and derealization are also part of other disorders, including panic and acute stress disorder. B. Depersonalization disorder is a very rare condition involving severe and frightening feelings of unreality and detachment such that they dominate an individual’s life and interfere with normal functioning. The textbook illustrates depersonalization disorder with the case of Bonnie. 1. Primary problem involves depersonalization and derealization. 2. Limited data suggest that 50% of persons suffering from depersonalization disorder also have another mood or anxiety disorder; mean onset is approximately 16.1 years of age, and the disorder tends to be chronic. 3. Depersonalization is related to a distinct cognitive profile, reflecting cognitive deficits in attention, short-term memory, and spatial reasoning. Such persons are easily distracted. Such deficits correspond with reports of tunnel vision (i.e., perceptual distortions) and mind emptiness (i.e., difficulty absorbing new information). SOMATOFORM AND DISSOCIATIVE DISORDERS - 9 C. Dissociative amnesia represents several forms of psychogenic memory loss and is most often found in females. The textbook illustrates dissociative amnesia with the case of "The Woman Who Lost Her Memory." 1. Those with generalized amnesia are unable to recall anything, including their identity. Generalized amnesia may be lifelong or may extend from a period in the more recent past. 2. More common is localized or selective amnesia, or a failure to recall specific (usually traumatic) events during a specific period of time. In most cases of amnesia, the forgetting is very selective for traumatic events or memories rather than being generalized. D. Dissociative fugue is related to dissociative amnesia. Persons with dissociative fugue just take off, and later find themselves in a new place, unable to remember why or how they got there, including an inability to recall their past. Often a new identity is assumed. Dissociative amnesia and fugue usually begin in adulthood, with rapid onset and dissipation, and most are female. Dissociative fugue is illustrated in the textbook with the case of the misbehaving sheriff. 1. A related non-Western variation of dissociative fugue is called amok (as in running amok). This disorder is most often seen in males and involves a trancelike state where the person often brutally assaults or sometimes kills persons or animals. Such persons usually do not remember the episode. E. Dissociative trance disorder represents a condition that differs in important ways across cultures. In this condition, the symptoms resemble those of other dissociative disorders, with the exception that dissociative symptoms and sudden changes in personality are attributed to possession of a spirit known to a particular culture. This disorder is more common in women and is often associated with some life stressor. Dissociative traces commonly occur in India, Nigeria, Thailand, and other Asian and African countries. This condition is considered abnormal only if the
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