Post on 26-Mar-2015
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 Conversion disorder Pain disorder Body dysmorphic disorder
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
Hypochondriasis: An Overview
Clinical Description (cont.) Little benefit from medical reassurance Strong disease conviction
Misperceptions of symptoms Checking behaviors High trait anxiety
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
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
Hypochondriasis
Culture-Specific Syndromes China – koro India – dhat Africa Pakistan
Hypochondriasis
Causes Disorder of cognition or perception
Physical signs and sensations
Hypochondriasis
Causes Familial history of illness
Genetics Modeling/learning
Other factors Stressful life events High family disease incidence “Benefits” of illness
Hypochondriasis - Treatment
Psychodynamic Uncover unconscious conflict Limited efficacy data
Educational & Supportive Ongoing and sensitive Detailed and repeated information Beneficial for mild cases
Hypochondriasis - Treatment
Cognitive-Behavioral Identify and challenge misinterpretations “Symptom creation” Stress-reduction Best efficacy data
Vs. medications (SSRI) Immediate and 1 year follow-up
Somatization Disorder
Clinical Description Long history of physical complaints Significant impairment Concern about symptoms, not meaning Symptoms = identity
Somatization Disorder
Statistics Rare
4.4%; 16.6% in medical settings Onset = adolescence Female : male = ~2:1
Unmarried, low SES Chronic course
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
Somatization Disorder: Treatment
No “cures” Cognitive-behavioral interventions
Initial reassurance Stress-reduction Reduce frequency of help-seeking behaviors
Somatization Disorder: Treatment
“Gatekeeper” physician Reduce visits to numerous specialists
Conditioning Reward positive health behaviors Punish problem behaviors
Remove supportive consequences
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
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?
Conversion Disorder
Statistics Rare Prevalence depends on setting Female > male Onset = adolescence Chronic, intermittent course
Conversion Disorder
Special populations Soldiers Children
Better prognosis?
Cultural considerations Religious experiences Rituals
Conversion Disorder: Causes
Freudian psychodynamic view Trauma, conflict experience Repression “Conversion” to physical symptoms
Primary gain Attention and support
Secondary gain
Conversion Disorder: Causes
Behavioral Traumatic event must be escaped Avoidance is not an option Social acceptability of illness Negative reinforcement
Conversion Disorder: Causes
Family/Social/Cultural Low SES Limited disease knowledge Family history of illness
Conversion Disorder: Treatment
Similar to somatization disorder Attending to trauma Remove secondary gain Reduce supportive consequences Reward positive health behaviors
Pain Disorder
Clinical Description Pain in one or more areas Significant impairment Etiology may be physical Maintained by psychological factors
Pain Disorder
Statistics Fairly common 5% - 12%
Treatment Combined medical and psychological
Body Dysmorphic Disorder
Clinical Description Preoccupation with imagined defect in
appearance Impaired function
Social Occupational
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?
Body Dysmorphic Disorder
Statistics 1% to 15% Female : Male = ~1:1
Different areas of focus Onset = early 20s Most remain single Lifelong, chronic course
Body Dysmorphic Disorder: Causes
Little scientific knowledge
Cultural imperatives Body size Skin color
Similarities with OCD Intrusive thoughts Rituals Age of onset and course
Body Dysmorphic Disorder: Treatment
Similar to OCD Medications (SSRIs) Exposure and response prevention
Plastic surgery is often unhelpful
Severe alterations or detachments
Normal perceptual experiences Significant impairments
Identity Memory Consciousness
Depersonalization Derealization
An Overview of Dissociative Disorders
An Overview of Dissociative Disorders
Types Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Trance Disorder Dissociative Identity Disorder
Depersonalization Disorder: An Overview
Clinical Description Feelings of unreality and detachment Severe/frightening Depersonalization Derealization Significant impairment
Depersonalization Disorder: An Overview
Statistics 0.8% Female : Male = ~1:1 High comorbidities
Anxiety and mood disorders Onset = ~ age 16 Lifelong, chronic course
Depersonalization Disorder: Causes
Cognitive deficits Attention Short-term memory Spatial reasoning Easily distracted
Decreased emotional response
Depersonalization Disorder: Treatment
Psychological treatments are unstudied Prozac appears ineffective
Dissociative Amnesia
Dissociative Amnesia Psychogenic memory loss Generalized type Localized or selective type
Dissociative Fugue
Dissociative Fugue: Flight or travel Memory loss
Retrograde vs. anterograde “How’s” or “why’s” of travel
Assumption of new identity
Dissociative Amnesia and Fugue
Statistics Tends to occur in adulthood Rapid onset Rapid dissipation Females > males
Dissociative Amnesia and Fugue
Causes and Treatments Little is known Trauma and life stress
Treatment Resolution without treatment Memory returns
Dissociative Trance Disorder
Clinical Description Dissociative symptoms Sudden personality changes State is undesirable
Cultural/religious variations
Dissociative Trance Disorder: An Overview
Statistics Female > male
Causes Life stressor or trauma
Treatment ?
Clinical Description Amnesia Dissociation of personality Adopt several new identities or “alters”
2 to 100 Average = 15 Unique characteristics
Host Switch
Dissociative Identity Disorder (DID)
Real vs. false memories Suggestibility Hypnosis studies Simulated amnesia Demand characteristics Physiological measures
Eye movements GSR EEG
Can DID be Faked?
Statistics 1.5% (year) Female : male = 9:1 Onset = childhood High comorbidity rates
Axis I Axis II
Lifelong, chronic course
Dissociative Identity Disorder (DID)
Causes Biological vulnerability
Reactivity Hippocampus and amygdala
Severe abuse/trauma history Links with PTSD
Highly suggestible Auto hypnotic model
DID: Causes
Similar to PTSD treatment Reintegration of identities Identify and neutralize cues/triggers Visualization Coping
Antidepressant medications?
DID: Treatment
Possible changes to the DSM-V Reorganization Physical and psychological origins “Health anxiety disorder” BDD and OCD Axis I or II classification
Future Directions