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Chapter 6

Chapter 6 - Somatoform and Dissociative Disorder

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Department
Psychology
Course Code
PSYC 3140
Professor
Kendra Thomson

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PSYC3140 Kendra Thomson December 4, 2013 Reading 10 Chapter 6 – Somatoform and Dissociative Disorders  Somatoform disorders: preoccupation with health or appearance becomes so great that it dominates their lives  Usually no identifiable medical condition causing physical complaints  Feeling “detached” from yourself or your surroundings  These mild sensations that most people experience periodically are slight alterations or detachments in consciousness or identity and they are known as dissociative experiences or dissociation  For some, these experiences are so intense and extreme that they lose their identity entirely an assume a new one or lose their memory or sense of reality and are unable to function – dissociative disorders  Somatoform and dissociative disorders are strongly linked historically  Used to be categorized under one general heading: hysterical neurosis  Hysteria suggests that the cause of these disorders which were thought to occur primarily in women because of the “wandering uterus’ (Hippocrates)  Hysterical came to refer more generally to physical symptoms without known organic cause or to dramatic or histrionic behaviour thought to be characteristic of women  Freud suggested that in a condition called conversion hysteria, unexplained physical symptoms indicated the conversion of unconscious emotional conflicts into a more acceptable form  The stigmatizing term hysterical is no longer used but conversion still used  Term neurosis, as defined in psychoanalytic theory, suggests specific cause for certain disorders  Neurotic disorders resulted from underlying unconscious conflicts, anxiety that resulted from those conflicts, and the implementation of ego defense mechanisms  Neurosis was eliminated from diagnostic system in 1980 because was too vague applying to almost all non-psychotic disorders and because it implied specific but unproven cause for these disorders – test Somatoform Disorders  DSM-IV lists five basic somatoform disorders: 1. Hypochondriasis 2. Somatization disorder 3. Conversion disorder 4. Pain disorder 5. Body dysmorphic disorder  First three overlap considerably and proposal in DSM-V is to combine these disorders into new category called complex somatic symptom disorder - test Hypochondriasis  Root from Greeks, hypochondria was region below the ribs, organs in this region affected mental state  Severe anxiety is focused on the possibility of having a serious disease  Threat seems so real that reassurance from physicians does not seem to help  Research indicates that 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 with hypochondriasis – test  DSM-V considering that hypochondriasis might be better considered to have an anxiety disorder – position receives wide support – test  Characterized by anxiety or fear that one has a serious disease  The essential problem is anxiety but its expression is different from that of other anxiety disorders  Individual is preoccupied with bodily symptoms, misinterpreting them as indicative of illness or disease  Almost any physical sensation may become the basis for concern  Usually go to family physicians initially  They come to attention of mental health professionals only after family physicians have ruled out realistic medical conditions as a cause  Important feature is that 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 - test  Individuals who mistakenly believe they currently have a disease are diagnosed with hypochondriasis – test  These two 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 than those with disease conviction  Individuals with panic disorder resemble hypochondriasis patients but the two conditions co-occur quite commonly – test  Patients with panic disorder also misinterpret physical symptoms as the beginning of the next panic attack, which they believe may kill them  Although both disorders include characteristic concern with physical symptoms, patients with panic disorder typically fear immediate symptom-related catastrophes that may occur during the few minutes they are having a panic attack  Individuals with hypochondriacal concerns focus on a long-term process of illness and disease (ex. cancer or AIDS) Statistics  Sex ratio is 50-50  Hypochondriasis is spread fairly evenly across various phases of adulthood – test o More elderly people go to doctor making absolute number of patients in this age group somewhat higher  As with most anxiety and mood disorders, hypochondriasis is chronic  Culture-specific syndromes seem to fit comfortably with hypochondriasis – test o Koro – belief, accompanied by severe anxiety and sometimes panic that the genitals are retracting into the abdomen – most are Chinese males  Typical sufferers are guilty about excessive masturbation, unsatisfactory intercourse, or promiscuity  These kinds of events may predispose men to focus their attention on their sexual organs, which could exacerbate anxiety and arousal, much as it does in the anxiety disorders o Culture-specific disorder prevalent in India is called dhat – anxious concern about losing semen, something that occurs during sexual activity  Associated with vague mix of physical symptoms including dizziness, weakness and fatigue that are not specific as in koro  These low-grade depressive or anxious symptoms are simply attributed to a physical factor – semen loss o Other specific culture-bound somatic symptoms associated with emotional factors would include hot sensations in the head or a sensation of something crawling in the head – specific to African patients o Sensation of burning in the hand and feet – specific to Pakistan and India Causes  Almost everyone agrees that hypochondriasis is basically a disorder of cognition or perception with strong emotional contributions  Experience physical sensations common to all of us but they quickly focus their attention on these sensations  The act of focusing on yourself increases arousal and makes physical sensations seem more intense than they actually are*  If you tend to misinterpret these as symptoms of illness, your anxiety will increase further  Increase anxiety produces additional physical symptoms – vicious cycle  Tend to interpret ambiguous stimuli as threatening  “Better safe than sorry” approach to dealing with even minor symptoms  They have a very restrictive concept of health as being totally symptom-free  Hypochondriasis runs in families  This contribution may be non-specific such as tendency to overrespond to stress, and thus may be indistinguishable from the non-specific genetic contribution to anxiety disorders  Hyperresponsivity might combine with a tendency to view negative life events as unpredictable and uncontrollable – guarded at all times  These factors would constitute biological and psychological vulnerabilities to anxiety  Children with hypochondriasis often report the same kinds of symptoms that other family members may have reported at one time  Quite possible as in panic disorder that individuals who develop hypochondriasis have learned from family members to focus their anxiety on specific physical conditions and illness  Adults with elevated hypochondriasis reported more learning experiences in childhood around negative reactions to bodily symptoms than did adults with lower levels of same concerns  These learning experiences involved being rewarded by parents (instrumental learning) when the child expressed bodily complaints (being allowed to miss school or receiving more attention)  These experiences also involved observing a parent or other family member expressing anxiety about bodily sensations (vicarious learning) or having a parent or fam member verbally instruct the child that al bodily sensations are dangerous  Seems to develop in the context of a stressful life event as do many disorders including anxiety 1. Example of Kristen’s fear of breast cancer starting with female relative 2. People who develop hypochondriasis tend to have had a disproportionate incidence of disease in their family when they were children 3. Social and interpersonal influence may be operating  People who come from families in which illness is a major issue seem to have learned that an ill person is often paid increased attention  The “benefits” of being sick might contribute to development Treatment  Until recently, it was common clinical practice to uncover unconscious conflicts through psychodynamic psychotherapy  Effectiveness of this treatment have seldom been reported  CBT can be very effective - test  Involves techniques such as exposure to health and illness info that the patient may be avoiding due to health anxiety and learning challenge illness-related misinterpretations of benign bodily sensations (learning to challenge thoughts that a simple rash is a sign of cancer)  Study focused on identifying and challenging misinterpretations of physical sensations and on showing patients how to create symptoms by focusing attention on certain body areas  Bringing on their own symptoms persuaded many patients that such events were under their control  Some preliminary evidence exists of the effectiveness of antidepressant medications, especially SSRI’s – test  Psychoeducation was sufficient only for mild cases of hypochondriasis – test Somatization Disorder  Pierre Briquet described patients giving him endless list of somatic complaints for which he could find no medical basis  Formerly known as Briquet’s syndrome  Key difference between hypochondriasis and somatization disorder is that in the latter, the patient is not so afraid about having a disease o More concerned about the symptoms themselves, not with what they might mean o People with hypochondriasis often take immediate action on noticing a symptom  People with somatization disorder do not feel urgency to take on action but continually feel weak and ill + avoid exercising, thinking it will make them worse Statistics  DSM-IV has only 8 symptoms required o 4 pain symptoms  Head, abdomen, back, chest o 2 gastrointestinal symptoms  Nausea, diarrhea, vomiting o 1 sexual symptom  Excessive menstrual bleeding, erectile dysfunction o 1 pseudoneurologic symptom  Deafness, blindness, paralysis, aphonia (loss of voice)  People with only a few medically unexplained physical symptoms may experience sufficient distress and impairment of functioning to be considered to have a disorder that is called undifferentiated somatoform disorder o This disorder is just somatization with fewer than 8 symptoms  Prevalence in large number of patients tend to be women, unmarried and from lower socio-economic group  In addition to variety of somatic complaints, may also have psychological complaints (usually about anxiety or mood disorders)  Rates are relatively uniform around word for somatic complaints as is sex ratio Causes  Somatization disorder shares some features with hypochondriasis including history of family illness or injury during childhood  This is minor factor because countless families experience chronic illness or injuries without passing on sick role to children  Similar to etiological models of hypochondriasis, studies have found that patients with somatization disorder are more sensitive to physical sensations or over- attend to them  Studies a possible genetic contributions had mixed results Somatization disorder is strongly linked in family and genetic studies to antisocial personality disorder  Antisocial personality disorder (ASPD) occurs primarily in males and somatization disorder and females but they share several features  Both begin early in life, typically run a chronic course, predominate among lower socioeconomic classes, are difficult to treat and are associated with marital discord, drug and alcohol abuse and suicide attempts  ASPD and somatization disorder tend to run in families and may have a heritable component  The aggressiveness, impulsiveness and lack of emotion characteristic of ASPD seem to be at the other end of the spectrum from somatization disorder  One model suggests that somatization disorder and ASPD share a neurobiologically based disinhibition syndrome characterized by impulsive behavior  Many of the behaviors and traits associated with somatization disorder also seem to reflect short-term gain at the expense of long-term problems  The continual development of new somatic symptoms gains immediate sympathy and attention but eventually social isolation  As individuals with ASPVD and somatization disorder share the same underlying neurophysiological vulnerability why do they behave so differently? o Social and cultural factors exert a strong effect  The major difference between the disorders is their degree of dependence  Aggression is strongly associated with males in most mammalian species  It is possible that gender socialization accounts almost entirely for the profound differences in the expression of the same biological vulnerability among men and women Treatment  Difficult to treat and no treatments exist with proven effectiveness to cure the syndrome  People with somatization disorder are very resistant to having a psychological cause applied to their physical symptoms and this resistance makes unlikely to avoid or discontinue psychological treatment  Clinics focus on providing reassurance, reducing stress and reducing the frequency of help seeking behaviors  Random studies demonstrate that written consultation letters sent to referring physicians to educate them about somatization disorder are effective in reducing the excessive and costly help seeking associated with this type of the somatoform disorder  Unfortunately this kind of intervention doesn’t improve psychological distress  Group cognitive behavioral therapy (CBT) has been shown to provide additional benefit not only and reducing healthcare costs but also in improving somatization disorder patients’ psychological well-being Conversion Disorder  The term conversion  Popularized by Freud who believed the anxiety resulting from unconscious conflicts somehow was converted into physical symptoms to find expression  This conversion allowed the individual to discharge some anxiety without actually experiencing it  As in phobic disorders, the anxiety resulting from unconscious conflicts might be displaced onto another object Clinical Description  Conversion disorders early have to do with physical malfunctioning such as paralysis, blindness or difficulty speaking (aphonia) without any physical or organic pathology  Most conversion symptoms suggest that some kind of neurological disease is affecting sensory motor systems  Conversion symptoms can mimic the full range of physical malfunctioning  Conversion symptoms may include the loss of the sense of touch  Some people have seizures which may be psychological in origin because no significant EEG changes can be documented  Another relatively common symptom is globus hystericus (the sensation of a long in the throat that makes it difficult to swallow, eat or sometimes talk)  Can also include aphonia or even total Mutism Closely Related Disorders  Distinguishing b/w conversion reactions, real physical disorders and malingering (faking) is sometimes difficult  Conversion reactions often have the same quality of indifference to the symptoms that is present in somatization disorder – this attitude is called la belle indifference o This attitude is sometimes displayed by people with actual physical disorders and some people with conversion disorders do become distressed so not always accurate  Gems are often precipitated by marked stress (often takes form of a physical injury  Marked stress preceding the conversion symptoms occurred in a high percentage of the study patients  People with conversion symptoms can usually function normally but they seem truly unaware either of this ability or of sensory input o For example individuals with the conversion symptom of blindness can usually avoid objects in their visual field but I will call you but cannot see the objects o Similarly individuals with conversion symptoms of paralysis of the legs might suddenly got up and run an emergency and then be shocked they did  Possible that at least some people experience miraculous cures during religious ceremonies may have been suffering from conversion reactions  Also very difficult to distinguish between individuals who are truly experiencing conversion symptoms in a seemingly involuntary weight and malingerer's for very good at faking symptoms  Malingerer's are either trying to get out of something (work, legal problem) or they are attempting to gain something (financial settlement)  Malingerer’s are fully aware of what they are doing and are clearly attempting to manipulate others to gain the desired reward  A puzzling condition is called factitious disorder which falls somewhere between malingering and conversion disorders  The symptoms are under voluntary control like malingering but the person has no obvious reason for voluntarily producing the symptoms except maybe to assume the sick role and received increased attention  May extend to producing symptoms in other fam members  An adult (almost always the mother) may make her child sick evidentially for the attention and pity then get into the mother o Called factitious disorder by proxy or sometimes Munchausen syndrome by proxy  Mother typically establishes a positive relationship with a medical staff, so her true nature is most often unsuspected and the staff perceives the parent as remarkably caring and totally uninvolved in providing for her child’s well-being  In one case of a child was suffering from recurring infections and cameras caught the mother injecting her own urine into the child intravenous line Unconscious Mental Processes in Conversion and Related Disorders  One study evaluated the potential difference between real unconscious process and faking by hypnotizing two subjects and giving each a suggestion of total blindness o One subject was also told it was extremely important that she appears to everyone to be blind o The second subject was not given further instructions o The first subject performed far below chance on a visual discrimination task (on almost every trial she chose the wrong answer) o The second subject with the hypnotic suggestion of blindness but no instructions to appear blind performed perfectly on the visual discrimination tasks although she reported she cannot see anything  An earlier case evaluated a male who seemed to have a conversion symptom of blindness o They discovered that he performed more poorly than chance on a visual discrimination task o Subsequent information confirmed he was malingering  To review these distinctions someone who is truly blind would perform at a chance level on visual discrimination tasks  People with conversion symptoms can see objects in their visual field but this experience is disassociate from their awareness of sight Statistics  Conversion disorder may occur in conjunction with other disorders particularly somatization disorder  Found primarily in women but occur in males at times of extreme stress  In some cultures conversion symptoms are very common aspects of religious or healing rituals - these are often seen as evidence of contact with G-d  These symptoms do not meet criteria for a disorder unless they could assist and interfere with an individual’s functioning Causes  Freud described for basic processes in the development of conversion disorder 1. The individual experiences a traumatic event – an unacceptable, unconscious conflict 2. Because the conflict and the resulting anxiety are unacceptable, the person represses the conflict making it unconscious 3. The anxiety continues to increase and presents to emerge into consciousness and the person “converts” it into physical symptoms thereby relieving the pressure of having to deal directly with the conflict a. This reduction of anxiety is considered to be the primary gain or reinforcing events that maintain the conversion symptom 4. The individual receives greatly increased attention and sympathy from loved ones and may also be allowed to avoid a difficult situation or task a. Such attention or avoidance is considered the secondary gain  Evidence supporting any of these ideas is sparse & for reviews were far more complex than represented here  What seems to happen is that people with conversion disorder have experienced a traumatic event or events that must be escaped at all costs  This might be combat where death is imminent  Because running away is unacceptable in most cases the socially excepted alternative of getting sick is substituted o But getting sick on purpose is also unacceptable so this motivation is detached from the person’s consciousness  The one step in Freud's progression of events about which some questions remain is a practice you a primary gain  The notion of primary gain accounts for the feature of la belle indifference where individuals do not seem distressed about their symptoms  Freud thought that because symptoms reflected an unconscious attempt to resolve a conflict the patient would not be upset by them  However, patients with conversion disorder are in fact often quite distressed by the symptoms*  Social and cultural influences also contribute to conversion disorder which tends to occur in the less educated and lower socioeconomic groups in which knowledge about disease and medical illness is not well-developed (like somatization disorder)  Prior experience with real physical problems usually among other family members tend to influence the later choice of specific conversion symptoms – patients tend to adopt symptoms with which they are familiar  Biological vulnerability to develop the disorder when under stress  Exposure to dramatic events may play large contributing role  However biological contributory factors seem to be less important than the overriding influence of interpersonal factors Treatment  Conversion disorder has much in common with somatization disorder so many of the treatment principles are similar  Principal strategy is to identify and attend to the traumatic or stressful life event and remove, if possible, sources of secondary gain  Therapeutic assistance in re-experiencing reliving (catharsis) the event is a reasonable first step  CBT programs appear promising Pain Disorder  The related somatoform disorder about which little is known is pain disorder  The person may have had a clear physical reasons for pain initially but psychological factors play a major role in maintaining it o Particularly anxiety focused on experience of pain  Important feature of pain disorder is that the pain is real and it hurts  When patients described their symptoms, those with predominantly physical pain differed in sever
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