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Chapter 6

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Psychology 2030A/B
David Vollick

Abnormal  Psychology  Chapter  6:   Somatoform  and  Dissociative  Disorders     Introduction   • Somatoform  Disorders:  physical  disorders  were  there  is  usually  no   identifiable  medical  condition  causing  the  physical  complaints   • Dissociative  Disorders:  feel  “detached”  from  yourself  or  your  surroundings   and  during  these  experiences  some  people  feel  as  if  they  are  dreaming   • Somatoform  and  dissociative  disorders  are  very  strongly  linked  histrionically   and  share  common  features   • Used  to  be  categorized  as  hysterical  neurosis   • Freud  termed  conversion  hysteria  which  are  unexplained  physical  symptoms   indicated  the  conversion  of  unconscious  emotional  conflicts  into  a  more   acceptable  form   • The  term  neurosis  suggested  a  specific  cause  for  certain  disorders     Somatoform  Disorders   • DSM-­‐IV-­‐TR  lists  five  basic  somatoform  disorders:   o Hypochondriasis     o Somatization  Disorder   o Conversion  Disorder   o Pain  Disorder   o Body  Dysmorphic  Disorder   • In  each,  individuals  are  pathologically  concerned  with  the  appearance  or   functioning  of  their  bodies     Hypochondriasis:  Clinical  Description   • Hypochondriasis:  severe  anxiety  is  focused  on  the  possibility  of  having  a   serious  disease   • Hypochondriasis  shares  many  features  with  the  anxiety  and  mood  disorders,   particularly  panic  disorder,  including  similar  age  of  onset,  personality   characteristics,  and  patterns  of  familial  aggregation   • Anxiety  and  mood  disorders  are  frequently  comorbid   • The  individual  is  preoccupies  with  bodily  symptoms,  misinterpreting  them  as   indicative  of  illness  or  disease   • Almost  any  physical  sensation  may  become  the  basis  for  concern   • Reassurances  from  numerous  doctors  that  the  individual  is  healthy  have,  at   best,  only  a  short  term  effect   • Individuals  who  have  only  marked  fear  of  developing  a  disease  are  classified   as  having  an  illness  phobia   • Individuals  who  mistakenly  believe  they  currently  have  a  disease  are   diagnosed  with  hypochondriasis   • Cote  shows  that  groups  differ  further   • Individuals  with  high  disease  conviction  are  more  likely  to  misinterpret   physical  symptoms  and  display  higher  rates  of  checking  behaviours  and  trait   anxiety  than  individuals  with  illness  phobia   • Individuals  with  illness  phobia  have  an  earlier  age  of  onset   • Disease  conviction  has  become  the  core  feature  of  hypochondriasis   • Panic  disorder  and  hypochondriasis  co-­‐occur  quite  commonly   • Panic  disorder  also  misinterpret  physical  symptoms   • Important  differences   o Patients  with  panic  disorder  fear  immediate  symptom-­‐related   catastrophes,  while  hypochondriacal  focus  on  long-­‐term  process  of   illness  and  disease   o Panic  disorder  individuals  tend  to  focus  on  the  specific  set  of  10-­‐15   sympathetic  nervous  system  symptoms  associated  with  a  panic  attack.   Hypochondriacal  concerns  range  much  wider     Hypochondriasis:  Statistics   • 1-­‐14%  of  the  population  are  diagnosed  with  hypochondriasis   • Sex  ratio  is  actually  50-­‐50   • Hypochondriasis  is  spread  fairly  evenly  across  various  phases  of  adulthood   • Peak  age  periods  found  in  adolescence,  middle  age,  and  after  60   • Hypochondriasis  is  chronic   • Koro  is  a  belief  that  the  genitals  are  retracting  into  the  abdomen.  Most   victims  are  Chinese  males   • In  India  the  concern  about  losing  semen  is  called  dhat.  Physical  symptoms   include  dizziness,  weakness,  and  fatigue   • Somatic  symptoms  are  more  challenging   1. A  physician  must  rule  out  a  physical  cause  for  the  somatic  complaints   before  referring  the  patient  to  a  mental  health  professional     2. The  mental  health  professional  must  determine  the  nature  of  the   somatic  complaints  in  order  to  know  whether  they  are  associated   with  a  specific  somatoform  disorder  or  are  part  of  some  other   psychopathological  syndrome   3. The  clinician  must  be  acutely  aware  of  the  specific  culture  or   subculture  of  the  patient     Hypochondriasis:  Causes   • Hypochondriasis  is  basically  a  disorder  of  cognition  or  perception  with   strong  emotional  contributions   • Experience  physical  sensation     • Increased  anxiety  produces  additional  physical  symptoms   • Enhanced  perceptual  sensitivity  to  illness  cues   • Tend  to  interpret  ambiguous  stimuli  as  threatening   • Hypochondriasis  runs  in  families  suggesting  a  possible  genetic  contribution   • Possible  that  individuals  who  develop  hypochondriasis  have  learned  from   family  members  to  focus  their  anxiety  on  specific  physical  conditions  and   illness   • Three  other  factors  may  contribute  to  their  ethological  process:   1. Develop  in  the  context  of  a  stressful  life  event   2. Tend  to  have  had  a  disproportionate  incidence  of  disease  in   their  family  when  they  were  children   3. An  important  social  and  interpersonal  influence  may  be   operating     Hypochondriasis:  Treatment   • Uncover  unconscious  conflicts  through  psychodynamic  psychotherapy   • Effectiveness  of  this  kind  of  treatment  have  seldom  been  reported   • CBT  can  be  very  effective   • Techniques  as  exposure  to  health  and  illness  information  and  learning  to   challenge  illness-­‐related  misinterpretations  of  benign  bodily  sensations   • 83%  of  patients  no  longer  meet  diagnostic  criteria  for  hypochondriasis  after   CBT   • Another  recent  innovation  in  CNT  for  hypochondriasis  has  been  to  adapt   treatments  that  have  been  shown  to  be  effective  with  related  disorders   • Effectiveness  of  antidepressant  medications,  especially  the  SSRIs   • CBT  is  the  most  effective  treatment   • Fluoxetime  (an  SSRI)  appears  promising   • Psychoeducation  as  sufficient  only  for  mild  cases  of  hypochondriasis     Somatization  Disorder:  Clinical  Description   • Somatization  Disorder:  involve  extreme  and  long-­‐lasting  focus  on  multiple   physical  symptoms  for  which  no  medical  cause  is  evident   • People  with  somatization  disorder,  do  not  feel  the  urgency  to  take  action  but   continually  feel  weak  and  ill,  and  they  avoid  experiencing,  thinking  it  will   make  them  worse     Somatization  Disorder:  Statistics   • DSM-­‐III-­‐R  criteria  required  13  out  of  35  symptoms,  making  a  diagnosis   difficult   • DSM-­‐IV  simplified  the  criteria  requiring  only  8  symptoms   • Katon  et  al.  demonstrated  that  somatization  disorder  occurs  on  a  continuum   • Using  between  4-­‐6  symptoms  as  criteria,  Escobar  and  Canino  found  a   prevalence  of  somatization  disorder  of  4.4%  in  one  large  city   • Individuals  with  somatization  disorder  tend  to  be  women,  unmarried  and   from  lower-­‐socioeconomic  groups   • Rates  are  relatively  uniform  around  the  world  for  somatic  complaints,  as  in   the  sex  ratio     Somatization  Disorder:  Causes   • History  of  family  illness  or  injury  during  childhood   • Kirmayer  theorized  that  patients  with  somatization  disorder  are  more   sensitive  to  physical  sensations  or  over-­‐attend  to  them   • Possible  genetic  contributions   • Somatization  disorder  is  strongly  linked  in  family  and  genetic  studies  to   antisocial  personality  disorder  (ASPD)   • Individuals  with  antisocial  personality  disorder  seem  insensitive  to  signals  of   punishment  and  to  the  negative  consequences  of  their  often  impulsive   behaviour,  and  experience  little  anxiety  or  guilt   • ASPD  occurs  primarily  in  males  and  somatization  disorders  in  females,  but   they  share  several  features:   o Begin  early  in  life   o Typically  run  a  chronic  course   o Predominate  among  lower  SES   o Difficult  to  treat   o Associated  with  marital  discord,  drug  and  alcohol  abuse,  and  suicide   attempts   o Tend  to  run  in  families  and  may  well  have  a  heritable  component   • Somatization  disorder  and  ASPD  share  a  neurobiologically  based   disinhibition  syndrome  characterized  by  impulsive  behaviour   • Individuals  with  somatization  disorder  and  ASPS  behave  differently  despite   their  similarities  because  of:   o  Social  and  cultural  factors  exert  a  strong  effect   o Gender  roles  are  among  the  strongest  components  of  identity   • These  theoretical  models  are  still  preliminary  and  require  a  great  deal  more   data  before  we  can  have  confidence  in  their  validity     Somatization  Disorder:  Treatment   • No  treatments  exist  with  proven  effectiveness  to  “cure:  the  syndrome   • Kirmayer  noted  that  people  with  somatization  disorder  are  very  resistant  to   having  a  psychological  cause  applied  to  their  physical  symptoms,  and  this   resistance  makes  them  likely  to  avoid  or  discontinue  psychological  treatment   • Concentrate  on  providing  reassurance,  reducing  stress,  and  in  particular,   reducing  the  frequency  of  help-­‐seeking  behaviours   • Additional  therapeutic  attention  is  directed  at  reducing  the  supportive   consequences  of  relating  to  significant  others  on  the  basis  of  physical   symptoms  alone   • Group  cognitive-­‐behavioural  therapy  has  been  shown  to  provide  additional   benefit  not  only  in  reducing  health  care  costs  but  also  in  improving   somatization  disorder  patients  psychological  well-­‐being     Conversion  Disorder:  Clinical  Description   • Conversion  Disorders:  physical  malfunctioning,  such  as  paralysis,  blindness,   or  difficulty  speaking,  without  any  physical  or  organic  pathology  to  account   for  the  malfunction   • Most  conversion  symptoms  suggest  that  some  kind  of  neurological  disease  is   affecting  sensory-­‐motor  systems,  although  conversion  symptoms  can  mimic   the  full  range  of  physical  malfunctioning   • Conversion  symptoms  may  include  the  loss  of  the  sense  of  touch,  seizures,   globus  hystericus  (the  sensation  of  lump  in  the  throat),  and  aphonia  or  even   total  mutism     Conversion  Disorder:  Closely  Related  Disorders   • Distinguishing  among  conversion  reactions,  real  physical  disorders,  and   outright  malingering  (faking)  is  sometimes  difficult.   • Several  factors  can  help:   1. Conversion  reactions  often  have  the  same  quality  of   indifference  to  the  symptoms  that  is  present  in  somatization   disorder.  This  is  called  la  belle  indifference   2. Conversion  symptoms  are  often  precipitated  by  marked  stress   3. People  with  conversion  symptoms  can  usually  function   normally  they  seem  truly  unaware  either  of  this  ability  or  of   sensory  input   • Although  these  factors  may  help  in  distinguishing  between  conversion  an   organically  based  physical  disorders,  clinicians  sometimes  make  mistakes   • Misdiagnosis  of  conversion  disorders  that  is  between  5-­‐10%   • It  can  also  be  very  difficult  to  distinguish  between  individuals  who  are  truly   experiencing  conversion  symptoms  in  a  seemingly  involuntary  way  and   malingers  who  are  very  good  at  faking  symptoms   • Factitious  disorders  fall  somewhere  between  malingering  and  conversion   disorders   • Symptoms  are  under  voluntary  control,  but  the  person  has  no  obvious  reason   for  voluntarily  producing  the  symptoms     • This  disorder  may  extend  to  producing  symptoms  in  other  members  of  the   family  who  is  almost  always  a  mother.  This  is  called  factitious  disorder  by   proxy  or  Munchausen  syndrome  by  proxy   • Helpful  procedures  to  assess  the  possibility  of  Munchausen  syndrome  by   proxy  include  trial  separation  of  the  mother  and  the  child  or  video   surveillance  of  the  child  while  in  the  hospital     Conversion  Disorder:  Unconscious  Mental  Processes  in  Conversion  and  Related   Disorders   • We  are  all  capable  of  receiving  and  processing  information  in  a  number  of   sensory  channels  without  being  aware  of  it   • Someone  who  is  truly  bind  would  perform  at  a  chance  level  discrimination   tasks   • People  with  conversion  symptoms  can  see  objects  in  their  visual  field  and   therefore  would  perform  well  on  these  tasks   • Malingers  and  perhaps  individuals  with  factitious  disorders  simply  do   everything  possible  to  pretend  they  can’t  see     Conversion  Disorder:  Statistics   • Conversion  disorders  are  relatively  rare  in  mental  health  settings   • The  prevalence  estimates  in  neurological  settings  vary  dramatically  from  1-­‐ 30%   • Conversion  disorders  are  found  primarily  in  women  and  typically  develop   during  adolescence  or  slightly  thereafter   • They  occur  relatively  frequently  in  males  at  times  of  extreme  stress   • Symptoms  often  disappear  after  a  time,  only  to  return  later  in  the  same  or   similar  form  when  a  new  stressor  occurs   • In  some  cultures,  conversion  symptoms  are  very  common  aspects  of   religious  or  healing  rituals     Conversion  Disorder:  Causes   • Freud  described  for  basic  processes  in  the  development  of  conversion   disorder   1. The  individual  experiences  a  traumatic  event   2. The  person  represses  the  conflict,  making  it  unconscious   3. The  anxiety  continues  to  increase  and  threatens  to  emerge  into   consciousness  and  the  person  “converts”  it  into  physical   symptoms.     • This  is  called  the  primary  gain  that  maintains  the   conversion  symptom   4. The  individual  receives  greatly  increased  attention  and  sympathy   form  loved  ones  and  may  also  be  allowed  to  avoid  a  difficult   situation  or  task   • This  is  called  the  secondary  gain   • Major  mood  disorders  and  severe  emotional  stress  are  common  among   children  and  adolescents  with  the  conversion  disorder  of  pseudoseizures   • The  issue  of  primary  gain  accounts  for  the  feature  of  la  belle  indifference   • Patients  with  conversion  disorder  are  in  fact  often  quite  distressed  by  their   symptoms   • The  impression  of  indifference  may  be  more  in  the  mind  of  the  therapist  than   true  of  the  patient   • Social  and  cultural  influences  also  contribute  to  conversion  disorder  tends  to   occur  in  less  educated,  lower  socioeconomic  groups  in  which  knowledge   about  disease  and  medical  illness  is  not  well  developed   • Prior  experience  with  real  physical  problems,  usually  among  other  family   members,  tends  to  influence  the  later  choice  of  specific  conversion  symptoms   • The  incidence  of  these  disorders  has  decreased  over  the  decades   • In  some  cases,  individuals  may  have  a  marked  biological  vulnerability  to   develop  the  disorder  when  under  stress   • Biological  vulnerability  seem  to  be  less  important  that  the  overriding   influence  of  interpersonal  factors     Conversion  Disorder:  Treatment   • Because  conversion  disorder  has  much  in  common  with  somatization   disorder,  many  of  the  treatment  principles  are  similar   • A  principle  strategy  is  to  identify  and  attend  to  the  traumatic  or  stressful  life   event,  if  it  is  still  present  and  remove  if  possible   • Therapeutic  assistance  in  re-­‐experiencing  the  event   • Work  very  hard  to  reduce  any  reinforcing  or  supportive  consequences  of  the   conversion  symptoms   • Therapist  must  collaborate  with  both  the  patient  and  the  family  to  eliminate   such  self-­‐defeating  behaviours   • CBT  programs  appear  to  hold  promise  in  the  treatment  of  conversion   disorder     Pain  Disorder   • Pain  Disorder:  person  may  have  had  clear  physical  reasons  for  pain,  at  least   initially,  but  psychological  factors  play  a  major  role  in  maintaining  it   • Very  difficult  to  separate  the  cases  where  the  causes  were  judged  to  be   primarily  psychological  fro  the  ones  where  the  causes  are  primarily  physical   • The  prevalence  of  pain  disorder  is  unclear   • A  study  from  Germany  suggests  5-­‐12%  of  the  population  meet  the  criteria  for   pain  disorder   • The  pain  disorder  is  considered  “chronic”  when  it  has  persisted  for  6  months   or  more   • Evidence  suggests  that  looking  at  the  way  that  the  pain  is  described  by  the   patient  can  be  beneficial  in  making  decisions  about  whether  or  not  a   somatoform  pain  disorder  is  present   • Predominantly  physically  based  pain  more  often  described  a  clear   localization  of  the  pains,  and  were  better  able  to  link  their  pain  to  situations   that  could  increase  or  decrease  it       Body  Dysmorphic  Disorder:  Clinical  Description   • Body  Dysmorphic  Disorder  (BDD):  normal-­‐looking  people  imagine  they  are   so  ugly  they  are  unable  to  interact  with  others  or  otherwise  function   normally  for  fear  that  people  will  laugh  at  their  ugliness   • Many  people  with  this  disorder  become  fixated  on  mirrors  while  others   avoid  mirrors  to  an  almost  phobic  extent   • Suicidal  ideation,  suicide  attempts,  and  suicide  itself  are  frequent   consequences  of  this  disorder   • “Ideas  of  reference”,  which  means  they  think  everything  that  goes  on  in  their   world  somehow  is  related  to  them   • Patients  with  severe  cases  become  household  for  fear  of  showing  themselves   to  other  people   • About  50%  of  individuals  with  pain  disorder  are  absolutely  convinced  their   imagined  bodily  defect  was  real  and  a  reasonable  source  of  concern     Body  Dysmorphic  Disorder:  Statistics   • The  prevalence  of  BDD  is  hard  to  estimate  but  it  is  thought  that  it  is  more   common  than  we  had  previously  thought  and  that  without  some  sort  of   treatment  it  tends  to  run  a  lifelong  course   • Prevalence  of  BDD  is  2.2%,  with  adolescent  girls  more  dissatisfied  than   adolescent  boys  with  their  bodies   • Blacks  of  both  genders  are  ore  satisfied  with  their  bodies  than  Caucasians,   Asians,  and  Hispanics   • BDD  is  not  strongly  associated  with  one  sex  or  the  other   • Age  of  onset  ranges  from  early  adolescence  through  the  20’s  with  a  peak  age   of  18-­‐19   • The  degree  of  psychological  stress  and  impairment  was  generally  worse  than   comparable  indices  in  patients  with  depression,  diabetes,  or  a  recent
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