PSYB32H3 Chapter : ch.7 for PSYB32
19 Jul 2010
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Chapter 7: Somatoform and Dissociative Disorders
! Somatoform disorders: individual complains of bodily symptoms that suggest a physical defect or dysfunction- rather
dramatic in nature- but for which no physiological basis can be found
! Dissociative disorders: individual experiences disruption of consciousness, memory and identity
! The onset of both disorders is assumed by many to be related to some stressful experience and the two can co-occur
SOMATOFORM DISORDERS
! Psychological problems take a physical form; the physical symptoms have no physiological explanation and are not
under voluntary control; they are thought to be linked to psychological factors, presumably anxiety, and are assumed
to be psychologically caused.
! Bodily symptoms fall in two groups : arousal of ANS and accompanied with pallable distress in the form of anxiety
and depression and the other group reflects thoughts and intentions that are not consciously recognized
Pain disorders: psychological factors play main role in onset, maintenance and severity of pain
! Person experiences pain that causes significant distress and impairment; patient is unable to work and become
dependent on painkillers/tranquillizers
! The pain may have temporal relation to some conflict or stress, or it may allow individual to avoid some unpleasant
activity and to secure attention and sympathy not otherwise available
! Pain is not a simple sensory experience therefore deciding when pain becomes a somatoform is difficult
! Differentiation can be achieved in the way in which pain is described by the patient; a patient with physically based
pain localize it more specifically and give more sensory description and link their pain more clearly to situations that
increase or decrease it
Body dysmorphic disorder: preoccupation with imagined or exaggerated defects in physical appearance
! Some patients with disorder may spend hours each day checking on their defect, looking in the mirror
! Others take the steps to avoid being reminded of the defect by eliminating mirrors from their homes or camouflaging
the defect- these concerns are distressing and lead to frequent consultations with plastic surgeons
! Occurs mostly in women; begins in late adolescence and is comorbid with depression, social phobia, eating disorders
and thoughts of suicide
! BDD is chronic and only 9% of patients experience remission over the course of one year
! Can be misdiagnosed as OCD or delusional disorder therefore preoccupation with imagined defects in physical
appearance may therefore not be a disorder itself, but a symptom that occur in several disorders
Hypochondriasis: preoccupation with fears of having serious illness, despite medical reassurance to the contrary
! Begins in early adulthood and has a chronic course; frequent consumers of medical services and not likely to have
mood or anxiety disorders
! They overreact to ordinary physical sensations and minor abnormalities such as irregular heartbeat, sweating,
coughing, sore spot or stomach ache
! More likely than others to attribute physical sensations to an illness
! Patient make catastrophic interpretations of symptoms such as believing red spot on skin is skin cancer
! 5% of general population; Often co-occur with anxiety and mood disorders
! Health anxiety: health-related dears and beliefs, based on interpretations, or more often misinterpretations of body
signs and symptoms as being indicative of serious illness
! Health anxiety would be present in both hypocondriasis and an illness phobia
! Hypochondriasis is a fear of having an illness. An illness phobia is a fear of contracting an illness
! Illness attitudes scale (IAS) is one self-report measure that is used commonly by researchers to assess health anxiety;
intended to be 9-factor scale; IAS reliable for 1) worry about illness and pain (illness fears) 2) disease conviction
(illness beliefs) 3) health habits (safety seeking behaviours) 4) symptoms interference with lifestyle (disruptive
effects)
! IAS was used to confirm link b/w health anxiety and trait neuroticism; general neurotic syndrome regarded as
contributing factor in etiology of health anxiety along with more specific factors such as cognitive mechanisms
! After controlling medical morbidity, health anxiety has moderately heritable and environmental factors rather than
genetic factor—health anxiety is mostly learned
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! Cognitive factors featured in model of health anxiety: 1) critical precipitating incident 2) previous experience of
illness and related medical factors 3) presence of inflexible or negative cognitive assumptions 4) severity of anxiety
o Health anxiety will increase as a function of related increases in 1) perceived likelihood or probability of illness 2)
perceived cost, awfulness and burden of illness
o Health anxiety will decrease as function of 1) perceived ability to cope 2) perceived presence of rescue factors
Conversion Disorder: sensory and motor symptoms without any physiological cause
! Physiologically normal ppl experience sensory or motor symptoms such as sudden vision and paralysis, suggesting an
illness related to neurological damage of some sort, although body organs and NS are found to be fine
! Sufferers experience paralysis of arms/legs; seizures and coordination disturbances; a sensation of prickling, tingling
or creeping on skin; insensitivity to pain or loss of impairment of sensory sensations called anaesthesias
! Vision may be impaired
! Aphonia: loss of voice and all but whispered speech
! Ansonia: loss or impairment of sense of smell
! Appear suddenly in stressful situations, allowing individual to avoid some activity or responsibility or to receive badly
wanted attention
! Anxiety and psychological conflict are believed to convert into physical symptoms
! Hysteria was originally used to describe conversion disorders
! Symptoms develop in adolescence or early adulthood after undergoing life stress
! Episode may end abruptly but returns sooner or later; either in its original form or with symptoms of different nature
and site; prevalence is less than 1 % and more women are given the diagnosis
! Frequently comorbid with Axis I diagnoses such as depression, substance abuse and personality disorders (borderline
and histrionic personality disorders)
! Hysterical anaesthesias do not make anatomical sense
! Glove anaesthesia: rare syndrome in which individual experiences little or no sensation in part of the hand that would
be covered by a glove: this makes no anatomical sense because nerves here run continuously from hand up the arm
! Carpan tunnel syndrome: can produce symptoms similar to GA: nerves in the wrist run thru tunnel formed by the
wrist bones and membranes; tunnel can become swollen and may pinch nerves, leading to tingling, numbness and pin
in hand
! 60% of individuals who were diagnosed and re-checked 9 years later either died or developed symptoms of physical
diseases; high proportion had diseases of CNS
! With technological advances in detecting illness and disease, rate of misdiagnosis as declined
Malingering and Factitious disorder:
! Malingering: individual fakes an incapacity in order to avoid a responsibility or to achieve some goal
o Diagnosed when conversion-like symptoms are determined to be under voluntary control which is not thought to
be in the case in true conversion disorders
o To distinguish the two disorders clinicians attempt to determine whether symptoms have been consciously or
unconsciously adopted
o La belle indifference: characterized by relative lack of concern or a blasé attitude toward the symptoms: helps
distinguish the disorders—patient with conversion disorder sometimes demonstrate this behaviour and appear to be
willing and eager to talk endlessly and dramatically about their symptoms ; in contrast; malingerers are likely to be
more guarded and cautious because they consider interviews challenge or threat to the success of the lie
! Distinction is not foolproof and only on third of people with conversion disorders show la belle indifference
! Stoic attitude is found among people with verified medical disease
! Factitious disorder: patients intentionally produce physical symptoms or sometimes psychological ones
o They might make up symptoms like acute pain or inflect injuries on themselves
o Less likely linked to recognizable goal; motivation for adopting physical or psychological symptoms is much less
clear ; the individual wants to for some reason assume role of patient
o May also involve parent creating physical illnesses in a child: factitious disorder by proxy or Munchausen
syndrome by proxy
o Factitious disorder is more prevalent (6%) among adult psychiatric in patients than previously recognized
Somatisation: recurrent, multiple physical complaints that have no biological basis or physical cause for which medical
attention is sought
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! To meet diagnostic criteria the person must have 1) 4 pain symptoms in different locations 2) 2 gastrointestinal
symptoms 3) one sexual system other than pain 4) one pseudoneurological symptom (e.g. those of conversion
disorder)
! These symptoms cause impairment, particularly regarding work
! Specific symptoms may vary across cultures: burning hands or experience of ants crawling under skin are more
frequent in Asia and Africa than in North America
! Disorder may be more frequent in cultures that de-emphasize the overt display of emotion
! Shares common symptoms with CD; patient visits physician frequently and uses medically often; hospitalization and
surgery are common
! Menstrual difficulties and sexual indifference are frequent
! Patients present complaints in histrionic, exaggerated fashion or as part of a long, complicated medical history
! Comorbidity is high with anxiety and mood disorders, substance abuse and several personality disorders
! Lifetime prevalence of somatisation disorder is less than 0.5% of the population and more frequent among women and
patients in medical treatment
! Prevalence is higher in some south America counties and in Puerto Rico
! Reasonable to view a person’s culture as providing a concept of what distress is and how it can be communicated
! It typically begins in early adulthood
! Anxiety and depression are often reported as are behavioural and interpersonal problems
! SD seems to run in families; found in about 20% of 1st degree relatives of index cases
ETIOLOGY OF SOMATOFORM DISORDERS
! Patients with somatisation disorder are more sensitive to physical sensations, over attend to them or interpret them
catastrophically
! People wit SD may also have a memory bias for information that connotes physical threat
! Somatoform patients have greater supraliminal interferences for physical threat words presented as part of a stroop
task
! Explicit memory test indicated that patients had memory bias for physical threat words
! Behavioural view: various aches, discomforts and dysfunctions are manifestation of unrealistic anxiety about bodily
systems
! Patients have high levels of cortisol (indication that they are under stress)
! Extreme tension of an individual localises in stomach muscle (feeling of nausea and vomiting)
! Once normal functioning is disrupted, 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 a personal failing
Psychoanalytic Theory of Conversion Disorder
! Brueur and Freud propped that CD is caused when a person experiences an event that creates great emotional arousal
but the affect is not expressed and memory of the event is cut off from conscious experience
! Freud hypothesized that CD in women is rooted in an unresolved Electra complex: young female child becomes
sexually attached to her father, but these unacceptable impulses are repressed and the result is both preoccupation with
sex and at the same time an avoidance of it; sexual excitement reawakens these repressed impulses as an adolescent or
adult, creating anxiety which is then converted into a physical symptom
! Hysterical blindness: people who were hysterically blind were influenced by visual stimuli even though they
explicitly denied seeing them
! Celia case: two stage defensive response was 1) perceptual representations of visual stimuli are blocked from
awareness and on this basis ppl report themselves blind 2) information is extracted from perceptual representations
! Whether or not hysterically blind people unconsciously need to deny receiving perceptual info is viewed as dependent
on personality factors and motivation
! People with blind sight: have lesions to visual cortex and no damage to their eyes; they say they are blind but they
perform well on visual tasks; these people have vision but they don’t KNOW that they can see
! Freud postulated the existence of the unconscious , a repository of instinctual energy and repressed conflicts and
impulses
! Contemporary researchers reject the notions 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
! Stimuli and processes of which we are unaware can have a powerful influence on our behaviour
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Document Summary
somatoform disorders: individual complains of bodily symptoms that suggest a physical defect or dysfunction- rather dramatic in nature- but for which no physiological basis can be found. dissociative disorders: individual experiences disruption of consciousness, memory and identity. the onset of both disorders is assumed by many to be related to some stressful experience and the two can co-occur. psychological problems take a physical form; the physical symptoms have no physiological explanation and are not under voluntary control; they are thought to be linked to psychological factors, presumably anxiety, and are assumed to be psychologically caused. bodily symptoms fall in two groups : arousal of ans and accompanied with pallable distress in the form of anxiety and depression and the other group reflects thoughts and intentions that are not consciously recognized. Pain disorders: psychological factors play main role in onset, maintenance and severity of pain.
