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Chapter 7

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University of Toronto Scarborough
Konstantine Zakzanis

CHAPTER 7 SOMATOFORM AND DISSOCIATIVE DISORDERS: Somatoform and dissociative disorders are related to anxiety disorders in that, in early versions of the DSM, all these disorders were subsumed under the heading of neuroses because anxiety was considered the predominant underlying factor in each case. somatoform disorder: 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. dissociative disorder: 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 classes sometimes co-occur. SOMATOFORM DISORDERS: Psychological problems take a physical form, no known physiological explanation and are not under voluntary control. The bodily symptoms of these disorders fall typically into two groups: (a) One group of symptoms reflects arousal in the autonomic nervous system and is accompanied by palpable distress in the form of anxiety and depression. (b) The second group of symptoms reflects thoughts and intentions that are not consciously recognized. (SEE TABLE 7.1, page 194). Argument that somatoform disorders should be removed from the pending DSM-V has seven concerns: The terminology of the somatoform category is often unacceptable to patients The distinction between symptoms that are disease-based vs, those that are psychogenic may be more apparent than real There is great heterogeneity among the disorders the only common link is physical illness that is not attributable to an organic cause Somatoform disorders are incompatible with other cultures There is ambiguity in the stated exclusion criteria for the disorders The subcategories have often failed to achieve accepted standards of reliability. Somatoform disorders lack clearly defined thresholds in terms of the symptoms needed for a diagnosis. Pain disorder: the person experiences pain that causes significant distress and impairment; psychological factors are viewed as playing an important role in the onset, maintenance, and severity of the pain. The patient may be unable to work and may become dependent on painkillers or tranquilizers. - The pain may have a temporal relation to some conflict or stress, or it may allow the individual to avoid some unpleasant activity and to secure attention and sympathy not otherwise available. - Accurate diagnosis is difficult because the subjective experience of pain is always a psychologically influenced phenomenon. Body dysmorphic disorder (BDB): a person is preoccupied with an imagined or exaggerated defect in appearance, frequently in the face eg; facial wrinkles, excess facial hair, or the shape or size of the nose. - Women tend also to focus on the skin, hips, breasts and legs, whereas men are more inclined to believe they are too short, that their penises are too small, or that they have too much body hair. - Occurs mostly among women, typically begins in late adolescence, and is frequently comorbid with depression and social phobia, eating disorder and thoughts of suicide. - BDB is chronic. Preoccupation with imagined defects in physical appearance may not be a disorder itself, but a symptom that can occur in several disorders. Hypochondriasis: is a somatoform disorder in which individuals are preoccupied with persistent fears of having a serious disease, despite medical reassurance to the contrary. - Patients are frequent consumers of medical services and are likely to have mood or anxiety disorder. - Is evident in ~5% of the general population and is about as common as other psychiatric disorders. - Not well differentiated from somatisation disorder.- Focus is more on health anxiety rather than hypochondriasis per se. - Health anxiety: health related fears and beliefs, based on interpretations, or perhaps more often, misinterpretations, of bodily signs and symptoms as being indicative of serious illness. - Whereas hypochondriacs have a fear of having an illness, an illness phobia is a fear of contracting an illness. - The Illness Attidutes Scale (IAS) is one self-report measure that is used commonly by researchers to assess heath anxiety. Consists reliably of four factors: (1) worry about illness and pain (i.e. illness fears) (2) disease conviction (i.e. illness beliefs) (3) health habits (i.e. safety-seeking behaviours) (4) symptom interference with lifestyle (i.e. disruptive effects - Health anxiety is mostly learned. - Cognitive factors are featured in the model of health anxiety outlined by Salkovskis and Warwick. 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 negative cognitive assumptions (i.e. believing strongly that unexplained bodily changes are always a sign of serious illness (4) the severity of anxiety. The severity of anxiety is a function of two factors that will increase anxiety and two that will decrease it. o Health anxiety will increase multiplicatively as a function of related increases in (1) perceived likelihood or probability of illness and (2) the perceived presence of rescue factors (i.e the availability and perceived effectiveness of medical help). 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. - Suffere
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