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Chapter 7

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Konstantine Zakzanis

Chapter 7: Somatoform and Dissociative Disorders  anxiety may not be observed in somatoform and dissociative disorders.  In somatoform disorders, 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.  In dissociative disorders, 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 may sometimes co-occur. Somatoform Disorder  In somatoform disorders, psychological problems take a physical form. Physical symptoms are not under voluntary control.  See table 7.1, page 210 for the summary of somatoform disorders.  In pain disorder, the person experiences pain causes significant distress and impairment; psychological factors displaying an important role in the onset, maintenance, and severity of pain. Client may be unable to work and may become dependent on painkillers or tranquilizers. Pain may have temporal relation to some conflict or it may allow the individual to avoid some unpleasant activity and to secure attention and sympathy not otherwise available.  Clients with physically-based pain and to localize it more specifically, give more detailed sensory description, and link their pain more clearly to situations that increase or decrease it.  There is a positive association between reports of pain symptoms and diagnosis of several of the anxiety disorders and/or depression.  MRI studies found significant gray matter decreases in the prefrontal, cingulated and insular cortex, regions of the brain known to be critically involved with the modulation of subjective pain.  With body dysmorphic disorder (BDD), a person is preoccupied with an imagined or exaggerated defect in appearance, frequently in the face.  People with BDD are distressed and may lead to frequent consultations with plastic surgeons.  BDD occurs mostly among women, typically begins in late adolescence, and is frequently comorbid with depression and social phobia, eating disorders, thoughts of suicide, and substance abuse and personality disorders.  BDD is usually chronic, with only 9% of clients experiencing remission over the course of one year.  In hypochondriasis, individuals are preoccupied with persistent fears of having a serious disease, despite medical reassurance to the contrary.  The disorder typically begins in early adulthood and has a chronic course. Clients with this diagnosis are likely to have mood or anxiety disorders.  The theory is that they overreact to ordinary physical sensation and minor abnormalities.  Hypochondriasis is evident in about 5% of the general population.  There has been a debate whether hypochondriasis should be moved under health anxiety disorder.  Health anxiety has been defined as health related fears and beliefs, based on interpretation, or perhaps more often, misinterpretation, of bodily signs and symptoms as being indicative of serious illness.  Health anxiety is not limited to hypochondriasis but can also be linked with anxiety and mood disorders.  Health anxiety would be present in both hypochondriasis and an illness phobia. Whereas hypochondriasis is a fear of having an illness, an illness phobia is a fear of contracting an illness.  The Illness Attitude Scale (IAS) is used commonly to assess health anxiety. It consists of four factors: 1. Worry about illness and pain 2. Disease conviction (illness beliefs) 3. Health topics 4. Symptom interference with lifestyle  The IAS was used to confirm a link between health anxiety and the trait neuroticism.  A general neurotic syndrome is regarded as a contributing factor in the etiology of health anxiety along with more specific factors such as cognitive mechanisms.  Health anxiety was moderately heritable, but most of the variance was due to environmental factors. Health anxiety is mostly learned.  Cognitive factors are featured in the model of health anxiety. 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 or negative cognitive consumption 4. The severity of anxiety  The severity of anxiety, is a function of two factors that will increase anxiety and to that will decrease it. Health anxiety will increase multiplicatively as a function of related increases in (1) the perceived likelihood or probability of illness and (2) the perceived cost, awfulness, and the burden of illness.  Health anxiety will decrease as a function of (1) the perceived ability to cope and (2) the perceived presence of rescue factors. 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 Berkeley, tingling, or creeping on the skin; insensitivity to pain; or the loss or impairment of sensations, called anesthesias.  Aphonia is the loss of the voice and all but whispered speech.  Anosmia is the loss or impairment of the sense of smell.  The psychological nature of conversion symptoms as demonstrated by the fact that they appear suddenly in stressful situations, allowing the individual to avoid some activity or responsibility or to receive badly wanted attention.  Freud believed that the energy of repressed instinct was favored it into sensorimotor channels and blocked functioning.  Hysteria was originally used to describe conversion disorders.  Hippocrates considered conversion disorders as an affliction limited solely to women and was due to the wandering of the uterus through the body.  Conversion symptoms usually develop in adolescence her early output, typically after undergoing life stress.  Prevalence of conversion disorder is less than 1% and more women than men are given the diagnosis.  It is frequently comorbid with other axis one diagnoses such as depression, substance abuse, anxiety and dissociative disorders, and mood personality disorders, notably borderline and histroinic personality disorders. People with conversion symptoms frequently report a history of physical or sexual abuse.  Glove anesthesia is 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 anesthesia. Focus on Discovery 7.1  Conversion disorder is difficult to distinguish from malingering.  Malingering involves an individual faking an incapacity in order to avoid responsibility. Malingering is diagnosed when the conversion like symptoms are determined to be under voluntary control.  One aspect of behavior that can sometimes help distinguish the two disorders is known as la belle indifference characterized by a relative lack of concern or a blase attitude toward the symptoms.  Clients with conversion disorder appear willing and eager to talk endlessly and dramatically about their symptoms, but often without the concern one might expect.  Malingerers are likely to be more guarded and cautious, perhaps because they consider interviews a challenge or threat to the success of the lie.  Factitious disorder involves people intentionally producing physical symptoms. They may make up symptoms – reporting acute pain – or inflict injury on themselves.  Factitious disorder may also involve a parent creating physical illnesses in a child.  If someone is making themselves ill, the disorder is simply referred to as Munchausen syndrome. Somatization Disorder  Briquet’s syndrome is now referred to as somatization disorder.  The disorder is characterized by recurrent, multiple somatic complaints, with no apparent physical cause, for which medical attention is sought: 1. Four pain symptoms in different locations 2. two gastrointestinal symptoms 3. one sexual symptom other than pain 4. one pseudoneurological symptom  somatization disorder and conversion disorder share many symptoms, and both diagnosis may apply to the same person.  Visits to physicians are frequent, as is the use of medication. Hospitalization and even surgery are common. Menstrual difficulties and sexual indifference are frequent. Many people believe that they have been ailing all their lives.  Comorbidity is high with anxiety and mood disorders, substance abuse, and several personality disorders.  The lifetime prevalence of somatization disorder is estimated at less than .5% of the population; it is more frequent among women and among patients and medical treatment.  Burning hands or the experience of ants crawling under the skin are more frequent in Asia and Africa than in North America.  The disorder may be more frequent and cultures that deemphasized the overt display of emotion.  Somatization disorder typically begins in early adulthood. They also seem to run in families. Etiology of Somatoform Disorders Etiology of Somatization Disorder  People with somatization disorder may also have a memory bias for information that connotes physical threat.  A behavioral view of the disorder holds that various aches, discomforts and dysfunctions are the manifestation of unrealistic anxiety about bodily systems.  Clients with somatization disorder have high levels of cortisol, an indication that they are under stress. Perhaps the extreme tension of an individual localizes and stomach muscles, resulting in feelings of nausea or vomiting.  The illness behaviors characteristic of somatization disorder might be learned responses acquired via exposure to parental illness and health anxiety and childhood. Psychoanalytic Theory of Conversion Disorder  Bruer and Freud proposed that conversion disorder is caused when a person experiences an event that creates great emotional arousal, but the effect is not expressed in the memory of the event is set off from conscious experience.  Freud hypothesized that conversion disorder in women is rooted in an unresolved Electra complex. The anxiety is transformed or converted into physica
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