Chapter 7

1. Chapter 7 Somatoform and Dissociative Disorders Alice Cheng, Ph.D. University of Hartford

2. Somatoform Disorders • The somatoform disorders are a group of conditions • that involve physical symptoms and complaints suggesting the presence of a medical condition • without any evidence of physical pathology to account for them

3. Somatoform Disorders The word somatoform derives from the Greek soma, meaning “body.” Somatoform disorders - A disorder characterized by complaints of physical problems or symptoms that cannot be explained by physical causes. The concept of somatoform disorder presumes that the physical symptoms reflect psychological factors or conflicts.

4. Somatoform Disorders • Somatoform disorders follow one of five more or less distinct patterns • Hypochondriasis • Somatization disorder • Pain disorder • Conversion disorder • Body dysmorphic disorder

5. Overview of Somatoform Disorders

6. Somatoform Disorders Malingering - Faking illness in order to avoid work or duty. Factitious disorder - A disorder characterized by intentional fabrication of psychological or physical symptoms for no apparent gain. Münchausen syndrome - A type of factitious disorder characterized by the fabrication of medical symptoms. Münchausen syndrome by proxy

7. Hypochondriasis Hypochondriasis - A somatoform disorder characterized by misinterpretation of physical symptoms as signs of underlying serious disease. The fear persists despite medical reassurances that it is groundless. Hypochondriasis is believed to affect about 1% to 5% of the general population and about 5% of patients seeking medical care (APA, 2000; Barksy & Ahern, 2004).

9. Somatoform Disorders • People with hypochondriasis are preoccupied with fears of getting a serious disease or the idea that they already have one • Cognitive-behavioral views of hypochondriasis are most widely accepted • Cognitive-behavioral therapy can be a very effective treatment

10. Somatization Disorder Somatization disorder - A somatoform disorder characterized by repeated multiple complaints that cannot be explained by physical causes. These complaints persist for at least several years, and result either in the seeking of medical attention or in significant impairment in fulfilling social or occupational roles. Reported rates of somatization disorder vary from 0.2% to 2% in women to less than 0.2% in men (APA, 2000).

11. Somatoform Disorders • Somatization disorder is characterized by many different complaints of physical ailments • over several years beginning before age thirty • that are not adequately explained by independent findings of physical illness or injury • that lead to medical treatment or to significant life impairment

12. Somatoform Disorders • In addition to the requirement of multiple physical complaints, DSM-IV-TR lists four other symptom criteria needed for a diagnosis of somatization disorder can be made: • Four pain symptoms • Two gastrointestinal symptoms • One sexual symptom • One pseudoneurological symptom

13. Somatoform Disorders • Somatization disorder • usually starts in adolescence • is about ten times more common in women • often occurs with other disorders such as major depression or panic disorder • There may be a genetic predisposition to the disorder • Other contributory causal factors may include personality, cognitive, and learning variables

14. Somatoform Disorders • Somatization disorder is extremely difficult to treat • A combination of medical management and cognitive-behavioral therapy may be helpful

15. Somatoform Disorders • Pain disorderis characterized by the experience of persistent and severe in one or more areas of the body • The symptoms of pain disorder resemble the pain symptoms of somatization disorder, but with pain disorder, the other symptoms are not present

16. Pain Disorder Pain disorder - A somatoform disorder in which psychological factors are presumed to play a significant role in the development, severity, or course of chronic pain. The psychological factors may contribute to the development, severity, or maintenance of the pain. The pain is severe enough and persistent enough to interfere with the person’s daily functioning.

17. Somatoform Disorders • DSM-IV-TR specifies two coded subtypes of pain disorder: • Pain disorder associated with psychological factors • Pain disorder associated with both psychological factors and a general medical condition • Cognitive-behavioral techniques are widely used in the treatment of both subtypes of pain disorder

18. Somatoform Disorders • Conversion disorder involves a pattern in which symptoms or deficits affecting sensory or voluntary motor functions lead one to think a patient has a medical condition • Freud believed that the symptoms were an expression of repressed sexual energy

19. Somatoform Disorders • In contemporary terms, the primary gain for conversion symptoms is continued escape or avoidance of a stressful situation • Secondary gains include attention and financial compensation • Conversion disorders are no longer as prevalent as they once were

20. Somatoform Disorders • The symptoms of conversion disorder fall under one of the following four categories: • sensory symptoms or deficits • motor symptoms or deficits • seizures • mixed presentation from the first three categories • It is important that patients receive a thorough medical and neurological examination to rule out organic illness

21. Somatoform Disorders • Conversion disorders are considered distinct from malingering disorder or factitious disorder in which a person intentionally produces or grossly exaggerates physical symptoms • Knowledge of how best to treat conversion disorder is extremely limited

22. Conversion Disorder Conversion disorder - A somatoform disorder characterized by loss or impairment of physical function in the absence of any apparent organic cause. The person is not malingering. The physical symptoms usually come on suddenly in stressful situations. A soldier’s hand may become “paralyzed” during intense combat, for example. The fact that conversion symptoms first appear in the context of, or are aggravated by, conflicts or stressors suggest a psychological connection (APA, 2000).

24. Body Dysmorphic Disorder Body dysmorphic disorder (BDD) - A somatoform disorder characterized by preoccupation with an imagined or exaggerated physical defect of appearance. They may spend hours examining themselves in the mirror and go to extreme measures to correct the perceived defect, even undergoing invasive or unpleasant medical procedures, including unnecessary plastic surgery (Crerand et al., 2005). Others remove all mirrors from their homes so as not to be eminded of the glaring flaw in their appearance.

25. Somatoform Disorders • People with body dysmorphic disorder are obsessed with some perceived or imagined flaws in their appearance • Perhaps 1 to 2 percent of the general population suffers from the disorder • People with the disorder commonly have a depressive diagnosis • Many researchers believe BDD is closely related to OCD and eating disorders

26. Percentage of People with BDD Who Experienced a Problem due to BDD Attempted suicide 14 Thought about suicide 63 Psychiatrically hospitalized at least once 26 Periods of complete avoidance of work, school, etc. Felt depressed 94 80 Housebound for at least one week 29 Interference with work or academic functioning 90 Periods of avoidance of nearly all social interactions 95 Interference with social functioning 99 0 20 40 60 80 100

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28. Psychodynamic Theory According to psychodynamic theory, hysterical symptoms are functional: They allow the person to achieve primary gains and secondary gains. The primary gain of the symptoms is to allow the individual to keep internal conflicts repressed. Secondary gains from the symptoms are those that allow the individual to avoid burdensome responsibilities and to gain the support—rather than condemnation—of those around them.

29. Treatment of Somatoform Disorders The treatment approach that Freud pioneered, psychoanalysis, began with the treatment of hysteria, which is now termed conversion disorder. Psychoanalysis seeks to uncover and bring unconscious conflicts that originated in childhood into conscious awareness. Once the conflict is aired and worked through, the symptom is no longer needed and should disappear.

30. Learning Theory Learning theorists focus on the more direct reinforcing properties of the symptom and its secondary role in helping the individual avoid or escape anxiety-evoking situations. From the learning perspective, the symptoms in conversion and other somatoform disorders may also carry the benefits, or reinforcing properties, of the “sick role.” Some learning theorists link hypochondriasis and body dysmorphic disorder to obsessive–compulsive disorder.

31. Conceptual models of conversion disorder. Psychodynamic and learning theory offer conceptual models of conversion disorder that emphasize the role of conversion symptoms leading to escape or relief from anxiety.

32. Cognitive Theory Cognitive theorists have speculated that some cases of hypochondriasis may represent a type of self-handicapping strategy, a way of blaming poor performance on failing health (Smith, Snyder, & Perkins, 1983). Cognitive theorists speculate that hypochondriasis and panic disorder, which often occur together, may share a common cause: a distorted way of thinking that leads the person to misinterpret minor changes in bodily sensations as signs of pending catastrophe (Salkovskis & Clark, 1993)

33. Somatoform Disorders • Treatments include • Antidepressant medications • Cognitive-behavioral treatment focused on exposure and response prevention

34. Dissociative Disorders Dissociative disorder - A disorder characterized by disruption, or dissociation, of identity, memory, or consciousness. The major dissociative disorders include dissociative identity disorder, dissociative amnesia, dissociative fugue, and depersonalization disorder. In each case, there is a disruption or dissociation (“splitting off ”) of the functions of identity, memory, or consciousness that normally make us whole.

35. Dissociative Disorders • The dissociative disorders are a group of conditions involving disruptions in a person’s normally integrated functions of • consciousness • memory • identity • perception

36. Overview of Dissociative Disorders

37. Dissociative Disorders • In derealization one’s sense of the reality of the outside world is temporarily lost • In depersonalization one’s sense of one’s self and one’s reality is temporarily lost

38. Depersonalization Disorder Depersonalization - Feelings of unreality or detachment from one’s self or one’s body. Derealization - A sense of unreality about the outside world. Depersonalization disorder - A disorder characterized by persistent or recurrent episodes of depersonalization.

39. Dissociative Disorders • Dissociative amnesia involves a failure to recall previously stored personal information when that failure cannot be accounted for by ordinary forgetting • In a dissociative fugue the person also departs from home surroundings

41. Dissociative Amnesia Amnesia derives from the Greek roots a-, meaning “not,” and mnasthai, meaning “to remember.” Dissociative amnesia - A dissociative disorder in which a person experiences memory loss without any identifiable organic cause. Unlike some progressive forms of memory impairment, the memory loss in dissociative amnesia is reversible, although it may last for days, weeks, or even years.

42. “Jane Doe.” This woman, called “Jane Doe” by rescue workers, was found wandering in a Florida park in a dazed state. She reported she had no memory of her background or even who she was. Her parents recognized her after she appeared on a national TV program. She reportedly never regained her memory.

43. Dissociative Amnesia • Dissociative amnesia is divided into five distinct types of memory problems: • Localized amnesia. • Selective amnesia. • Generalized amnesia. • Continuous amnesia. • Systematized amnesia.

44. Dissociative Fugue Fugue derives from the Latin fugere, meaning “flight.” The word fugitive has the same origin. Fugue is like amnesia “on the run.” Dissociative fugue - A dissociative disorder in which one suddenly flees from one’s life situation, travels to a new location, assumes a new identity, and has amnesia for personal material.

45. Dissociative Disorders • Dissociative identity disorder is a dramatic dissociative disorder in which a patient manifests two or more distinct identities or personality states that alternate in some way in taking control of behavior

46. Dissociative Disorders Dissociative identity disorder - A dissociative disorder in which a person has two or more distinct, or alter, personalities. In dissociative identity disorder, two or more personalities—each with well-defined traits and memories—“occupy” one person. In the film, The Three Faces of Eve , Eve White is a timid housewife who harbors two other personalities: Eve Black, a sexually provocative, antisocial personality, and Jane, a balanced, developing personality who could balance her sexual needs with the demands of social acceptability.

48. The Three Faces of Eve In the classic film The Three Faces of Eve, a timid housewife, Eve White (left) harbors two alter personalities: Eve Black (middle), a libidinous and antisocial personality, and Jane (right), an integrated personality who can accept her sexual and aggressive urges but still engage in socially appropriate behavior. In the film, the three personalities are successfully integrated. In real life, however, the person depicted in the film reportedly split into 22 personalities later on.

49. Features In some cases, the host (main) personality is unaware of the existence of the other identities, whereas the other identities are aware of the existence of the host. In other cases, the different personalities are completely unaware of one another. Sometimes two personalities vie for control of the person.

50. Dissociative Disorders • Alters are not in any meaningful sense personalities • This disorder is quite rare • The disorder usually starts in childhood