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Chapter 6 Somatoform and Dissociative Disorders. An Overview of Somatoform Disorders. Soma = Body Preoccupation with health or appearance Physical complaints No identifiable medical condition. An Overview of Somatoform Disorders. Somatoform Disorders Hypochondriasis Somatization disorder

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Chapter 6Somatoform and Dissociative Disorders


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An Overview of Somatoform Disorders

  • Soma = Body

    • Preoccupation with health or appearance

    • Physical complaints

    • No identifiable medical condition


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An Overview of Somatoform Disorders

  • Somatoform Disorders

    • Hypochondriasis

    • Somatization disorder

    • Conversion disorder

    • Pain disorder

    • Body dysmorphic disorder


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Hypochondriasis: An Overview

  • Clinical Description

    • Anxiety or fear of having a disease

    • High comorbidity with anxiety/mood disorders

    • Focus on bodily symptoms

      • Normal

      • Mild

      • Vague


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Hypochondriasis: An Overview

  • Clinical Description (cont.)

    • Little benefit from medical reassurance

    • Strong disease conviction

      • Misperceptions of symptoms

      • Checking behaviors

      • High trait anxiety


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Hypochondriasis and Panic Disorder

  • Similarities

    • Focus on bodily symptoms

  • Differences in hypochondriasis:

    • Focus on long-term process of illness

    • Constant concern

    • Constant medical treatment seeking

    • Wider range of symptoms


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Hypochondriasis: An Overview

  • Statistics

    • 1% to 14% of medical patients

      • 6.7% median rate

    • Female : Male = 1:1

    • Onset at any age

      • Peaks: adolescence, middle age, elderly

    • Chronic course


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Hypochondriasis

  • Culture-Specific Syndromes

    • China – koro

    • India – dhat

    • Africa

    • Pakistan


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Hypochondriasis

  • Causes

    • Disorder of cognition or perception

      • Physical signs and sensations


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Hypochondriasis

  • Causes

    • Familial history of illness

      • Genetics

      • Modeling/learning

    • Other factors

      • Stressful life events

      • High family disease incidence

      • “Benefits” of illness


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Hypochondriasis - Treatment

  • Psychodynamic

    • Uncover unconscious conflict

    • Limited efficacy data

  • Educational & Supportive

    • Ongoing and sensitive

    • Detailed and repeated information

    • Beneficial for mild cases


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Hypochondriasis - Treatment

  • Cognitive-Behavioral

    • Identify and challenge misinterpretations

    • “Symptom creation”

    • Stress-reduction

    • Best efficacy data

      • Vs. medications (SSRI)

      • Immediate and 1 year follow-up


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Somatization Disorder

  • Clinical Description

    • Long history of physical complaints

    • Significant impairment

    • Concern about symptoms, not meaning

    • Symptoms = identity


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Somatization Disorder

  • Statistics

    • Rare

      • 4.4%; 16.6% in medical settings

    • Onset = adolescence

    • Female : male = ~2:1

      • Unmarried, low SES

    • Chronic course


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Somatization Disorder: Causes

  • History of family illness or injury

  • Links to antisocial personality disorder

    • Behavioral inhibition system

      • Impulsivity

      • Novelty-seeking

      • Provocative sexual behavior

    • Socialization

    • Gender roles


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Somatization Disorder: Treatment

  • No “cures”

  • Cognitive-behavioral interventions

    • Initial reassurance

    • Stress-reduction

    • Reduce frequency of help-seeking behaviors


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Somatization Disorder: Treatment

  • “Gatekeeper” physician

    • Reduce visits to numerous specialists

  • Conditioning

    • Reward positive health behaviors

    • Punish problem behaviors

      • Remove supportive consequences


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Conversion Disorder

  • Clinical Description

    • Physical malfunctioning

      • sensory-motor areas

    • Lack physical or organic pathology

    • Lack awareness

    • “La belle indifference”

      • Possible, but not always

    • Intact functioning


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Conversion Disorder : Differential Diagnosis

  • Malingering

    • Intentionally produced symptoms

    • Clear benefit

    • No precipitating stressful event

    • Impaired function

  • Factitious Disorder/Munchausen’s

    • Intentionally produced symptoms

    • No obvious benefit

      • Sick role?


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Conversion Disorder

  • Statistics

    • Rare

    • Prevalence depends on setting

    • Female > male

    • Onset = adolescence

    • Chronic, intermittent course


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Conversion Disorder

  • Special populations

    • Soldiers

    • Children

      • Better prognosis?

    • Cultural considerations

      • Religious experiences

      • Rituals


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Conversion Disorder: Causes

  • Freudian psychodynamic view

    • Trauma, conflict experience

    • Repression

    • “Conversion” to physical symptoms

      • Primary gain

    • Attention and support

      • Secondary gain


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Conversion Disorder: Causes

  • Behavioral

    • Traumatic event must be escaped

    • Avoidance is not an option

    • Social acceptability of illness

    • Negative reinforcement


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Conversion Disorder: Causes

  • Family/Social/Cultural

    • Low SES

    • Limited disease knowledge

    • Family history of illness


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Conversion Disorder: Treatment

  • Similar to somatization disorder

    • Attending to trauma

    • Remove secondary gain

    • Reduce supportive consequences

    • Reward positive health behaviors


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Pain Disorder

  • Clinical Description

    • Pain in one or more areas

    • Significant impairment

    • Etiology may be physical

    • Maintained by psychological factors


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Pain Disorder

  • Statistics

    • Fairly common

    • 5% - 12%

  • Treatment

    • Combined medical and psychological


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Body Dysmorphic Disorder

  • Clinical Description

    • Preoccupation with imagined defect in appearance

    • Impaired function

      • Social

      • Occupational


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Body Dysmorphic Disorder

  • Clinical Description

    • Fixation or avoidance of mirrors

    • Suicidal ideation and behavior

    • Unusual behaviors

      • Ideas of reference

      • Checking/compensating rituals

    • Delusional disorder: somatic type?


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Body Dysmorphic Disorder

  • Statistics

    • 1% to 15%

    • Female : Male = ~1:1

      • Different areas of focus

    • Onset = early 20s

    • Most remain single

    • Lifelong, chronic course


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Body Dysmorphic Disorder: Causes

  • Little scientific knowledge

  • Cultural imperatives

    • Body size

    • Skin color

  • Similarities with OCD

    • Intrusive thoughts

    • Rituals

    • Age of onset and course


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Body Dysmorphic Disorder: Treatment

  • Similar to OCD

    • Medications (SSRIs)

    • Exposure and response prevention

  • Plastic surgery is often unhelpful


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An Overview of Dissociative Disorders

  • Severe alterations or detachments

    • Normal perceptual experiences

  • Significant impairments

    • Identity

    • Memory

    • Consciousness

  • Depersonalization

  • Derealization


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An Overview of Dissociative Disorders

  • Types

    • Depersonalization Disorder

    • Dissociative Amnesia

    • Dissociative Fugue

    • Dissociative Trance Disorder

    • Dissociative Identity Disorder


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Depersonalization Disorder: An Overview

  • Clinical Description

    • Feelings of unreality and detachment

    • Severe/frightening

    • Depersonalization

    • Derealization

    • Significant impairment


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Depersonalization Disorder: An Overview

  • Statistics

    • 0.8%

    • Female : Male = ~1:1

    • High comorbidities

      • Anxiety and mood disorders

    • Onset = ~ age 16

    • Lifelong, chronic course


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Depersonalization Disorder: Causes

  • Cognitive deficits

    • Attention

    • Short-term memory

    • Spatial reasoning

    • Easily distracted

  • Decreased emotional response


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Depersonalization Disorder: Treatment

  • Psychological treatments are unstudied

  • Prozac appears ineffective


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Dissociative Amnesia

  • Dissociative Amnesia

    • Psychogenic memory loss

    • Generalized type

    • Localized or selective type


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Dissociative Fugue

  • Dissociative Fugue:

    • Flight or travel

    • Memory loss

      • Retrograde vs. anterograde

      • “How’s” or “why’s” of travel

    • Assumption of new identity


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Dissociative Amnesia and Fugue

  • Statistics

    • Tends to occur in adulthood

    • Rapid onset

    • Rapid dissipation

    • Females > males


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Dissociative Amnesia and Fugue

  • Causes and Treatments

    • Little is known

    • Trauma and life stress

  • Treatment

    • Resolution without treatment

    • Memory returns


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Dissociative Trance Disorder

  • Clinical Description

    • Dissociative symptoms

    • Sudden personality changes

    • State is undesirable

  • Cultural/religious variations


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Dissociative Trance Disorder: An Overview

  • Statistics

    • Female > male

  • Causes

    • Life stressor or trauma

  • Treatment

    • ?


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Dissociative Identity Disorder (DID)

  • Clinical Description

    • Amnesia

    • Dissociation of personality

    • Adopt several new identities or “alters”

      • 2 to 100

      • Average = 15

      • Unique characteristics

    • Host

    • Switch


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Can DID be Faked?

  • Real vs. false memories

  • Suggestibility

  • Hypnosis studies

  • Simulated amnesia

  • Demand characteristics

  • Physiological measures

    • Eye movements

    • GSR

    • EEG


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Dissociative Identity Disorder (DID)

  • Statistics

    • 1.5% (year)

    • Female : male = 9:1

    • Onset = childhood

    • High comorbidity rates

      • Axis I

      • Axis II

    • Lifelong, chronic course


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DID: Causes

  • Causes

    • Biological vulnerability

      • Reactivity

      • Hippocampus and amygdala

    • Severe abuse/trauma history

      • Links with PTSD

    • Highly suggestible

      • Auto hypnotic model


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DID: Treatment

  • Similar to PTSD treatment

    • Reintegration of identities

    • Identify and neutralize cues/triggers

    • Visualization

    • Coping

  • Antidepressant medications?


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Future Directions

  • Possible changes to the DSM-V

    • Reorganization

    • Physical and psychological origins

    • “Health anxiety disorder”

    • BDD and OCD

    • Axis I or II classification


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