Somatoform and Dissociative Disorders

1. Somatoform and Dissociative Disorders Chapter 5

2. Basic definitions • Somatoform disorders • pathological concern of individuals with the appearance or functioning of their bodies when there is no identifiable medical condition causing the physical complaints • Dissociative disorders • individuals feel detached from themselves or their surroundings, and reality, experience, and identity may disintegrate • Historically, both somatoform and dissociative disorders used to be categorized as hysterical neurosis • in psychoanalytic theory neurotic disorders result from underlying unconscious conflicts, anxiety that resulted from those conflicts and ego defense mechanisms

3. Somatoform Disorders • Soma – Meaning Body • Preoccupation with health and/or body appearance and functioning • No identifiable medical condition causing the physical complaints • Types of DSM-IV Somatoform Disorders • Hypochondriasis • Somatization disorder • Conversion disorder • Pain disorder • Body dysmorphic disorder

4. Somatoform Disorders • Hypochondriasis • severe anxiety focused on the possibility of having a serious disease • shares age of onset, personality characteristics anf running in families with panic disorder • illness phobia vs. hypochondriasis • 60% of patients with illness phobia develop hypochondriasis • 1% to 14% of medical patients • treatment usually invoves cognitive-behavioral therapy and general stress management treatment (gain retained after 1 year follow-up)

5. Somatoform Disorders • Causes of hypochondriasis

6. Somatoform Disorders • Somatization disorder • Briquet’s syndrome (100 years ago) • patients have a history of many physical complaints that can not be explained by a medical condition, the complaints are not intentionally produced • 20% of patients in primary care setting • develops during adolescence (majority women) • may be connected to Antisocial personality disorder • difficult to treat (reassurance, stress reduction, more adoptive methods of interacting with family are encouraged)

7. Somatoform Disorders • Conversion Disorder • Physical malfunctioning without any physical or organic pathology • Malfunctioning often involves sensory-motor areas • Persons show la belle indifference • Retain most normal functions, but without awareness of this ability • Statistics • Rare condition, with a chronic intermittent course • Seen primarily in females, with onset usually in adolescence • Not uncommon in some cultural and/or religious groups

8. Somatoform Disorders • Conversion disorder (cont.) • Freudian psychodynamic view is still popular (anxiety converted into physical symptoms) • Emphasis on the role of trauma (stress), conversion, and primary/secondary gain • Detachment from the trauma and negative reinforcement seem critical • Different from factitious disorder (intentional) • Treatment • Similar to somatization disorder • Core strategy is attending to the trauma • Remove sources of secondary gain • Reduce supportive consequences of talk about physical symptoms

9. Somatoform Disorders • Body Dysmorphic Disorder • Preoccupation with imagined defect in appearance • Either fixation or avoidance of mirrors • Previously known as dysmorphophobia • Suicidal ideation and behavior are common • Often display ideas of reference for imagined defect • Statistics • More common than previously thought • Usually runs a lifelong chronic course • Seen equally in males and females, with onset usually in early 20s • Most remain single, and many seek out plastic surgeons

10. Somatoform Disorders • Body Dysmorphic Disorder (cont.) • Causes • Little is known – Disorder tends to run in families • Shares similarities with obsessive-compulsive disorder • Treatment • Treatment parallels that for obsessive compulsive disorder • Medications (i.e., SSRIs) that work for OCD provide some relief • Exposure and response prevention are also helpful • Plastic surgery is often unhelpful

11. Dissociative Disorders • Derealization • Loss of sense of the reality of the external world • Depersonalization • Loss of sense of your own reality • 5 types • Depesonalization disorder • Dissociative amnesia • Dissociative fugue • Dissociative trance disorder • Dissociative identity disorder

12. Dissociative Disorders • Depersonalization disorder • Severe feelings of depersonalization dominate the individual’s life and prevent normal functioning • It is chronic • 50% suffer from additional mood and anxiety disorders • Cognitive profile (cognitive deficits in attention, STM, spatial reasoning, perception (3D))

13. Dissociative Disorders • Dissociative Amnesia • Inability to recall personal information, usually of a stressful or traumatic nature • Generalized vs. selective amnesia • Dissociative Fugue • Sudden, unexpected travel away from home, along with an inability to recall one’s past (new identity) • Occur in adulthood and usually end abruptly

14. Dissociative Disorders • Dissociative trance disorder • Altered state of consciousness in which the person believes firmly that he or she is possessed by spirits; considered a disorder only where there is distress and dysfunction • Trance and possession are a common part of some traditional religious and cultural practices and are not considered abnormal in that context • Only undesirable trance considered pathological within that culture is characterized as disorder

15. Dissociative Disorders • Dissociative Identity Disorder • Formerly multiple personality disorder • Many personalities (alters) or fragments of personalities coexist within one body • The personalities or fragments are dissociated • Switch (transition form one personality to another, includes physical changes) • Can be simulated by malingers are usually eager to demonstrate their symptoms whereas individuals with DID attempt to hide symptoms • Very high comorbidity • Prevalence about 3%

16. Dissociative Disorders • Dissociative Identity Disorder • Auditory hallucinations (coming from inside their heads) • 97% severe child abuse • Extreme subtype of PTSD • Onset – approximately 9 years • Suggestible people may use dissociation as defense against severe trauma • Real and false memories • Temporal lobe pathology (out of body experiences)

17. Dissociative Disorders • Treatment • Dissociative amnesia and fugue • Get better on their own • Coping mechanisms to prevent future episodes • DID • Reintegration of identities • Neutralization of cues • Confrontation of early trauma • hypnosis