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CHAPTER 5

SOMATOFORM AND DISSOCIATIVE DISORDERS

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AIMS AND OBJECTIVES

Define somatoform and dissociative disorders

Describe historical approaches

Review information regarding prevalence, age of onset, and course

Discuss current aetiological findings

Outline treatment approaches

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SOMATOFORM AND DISSOCIATIVE DISORDERS Somatoform disorders involve the presentation of medically

unexplained symptoms

Dissociative disorders involve the loss of normal integration of identity, memory, perception, or consciousness

Dissociation is the mechanism whereby one part of mental functioning (e.g., memory, consciousness, perception, or identity) is split off from the rest

Factitious disorders involve the deliberate feigning of illness, usually to gain the security or care of medical attention (e.g., Munchausen’s syndrome)

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SOMATOFORM AND DISSOCIATIVE DISORDERS

Historical approaches

The ancient term “hysteria,” referred to nonfatal malady of women that included different types of bodily symptoms

The most classic case of hysteria is Anna O, written by Joseph Breurer and Sigmund Freud

Anna O was a young Viennese woman who reported multiple somatoform symptoms, which were suggested to be associated with the psychological trauma of her father’s illness and death

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SOMATOFORM AND DISSOCIATIVE DISORDERS

Historical approaches

The term conversion signifies the transformation of psychological material into somatic symptoms

The treatment of Anna O was the first described case of the psychoanalysis, the “talking cure”

Freud theorised that hysteria was the result of consciously unacceptable sexual fantasies from childhood

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Somatoform disorders

To be assigned a somatoform disorder diagnosis, the symptoms must be understood to derive from psychological factors, rather than having a medical basis

DSM-IV-TR somatoform diagnoses include:

Conversion disorder - a motor or sensory neurological disturbance (e.g., paralysis) that onsets after a psychological stress, with no physical disorder to explain the impairment

Pain disorder - severe pain in one or more anatomical sites, not fully explainable by physical pathology

SOMATOFORM AND DISSOCIATIVE DISORDERS

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Somatoform disorders

DSM-IV-TR somatoform diagnoses (cont.)

Somatisation disorder - a history of multiple physical complaints in several different body sites, beginning before age 30 and occurring over several years

Hypochondriasis – Preoccupation with fears of having or belief that one has a serious disease despite appropriate medical reassurance

Body dysmorphic disorder – preoccupation with an imagined defect in appearance, with markedly excessive concern

SOMATOFORM AND DISSOCIATIVE DISORDERS

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Somatoform disorders

Epidemiology

Medically unexplained physical symptoms are common, not just in those with somatoform disorders

Formal clinical somatoform disorders are rare in the general community; much more prevalent among high utilisers of health services

Anxiety and depression are common in people with unexplained physical symptoms and those with somatoform disorder

Somatoform disorders are more common among women

SOMATOFORM AND DISSOCIATIVE DISORDERS

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Aetiology Biological factors

Research has found underactivity of hypothalamic-pituitary-adrenal (HPA) axis in patients with unexplained symptoms, such as fatigue

Neurobiological models focus on how sensory/motor info is processed

Gate Control Theory (Melzak & Wall, 1965) of pain: Neural “gates” in the spinal cord can be opened or closed, determining the

amount of pain the individual experiences More activity in the pain fibers more gates are opened More activity in the peripheral fibers regarding stimuli around the body

more gates are closed Messages from the brain can open or close the gates

SOMATOFORM AND DISSOCIATIVE DISORDERS

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Aetiology

Trauma and personality factors

Patients with somatoform disorders more likely to have experienced adverse events in childhood

One theory proposes that memory of early trauma is contained in emotions, reflex actions, or bodily sensations (van der Kolk, 1994)

Negative events in childhood may also give rise to personality characteristics that predispose the person to a somatoform disorder

People with somatoform disorders have higher rates of alexithymia, difficulty experiencing or expressing emotions

Failing to identify and express emotional distress may lead to

increased physiological arousal

SOMATOFORM AND DISSOCIATIVE DISORDERS

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Aetiology

Cognitive and behavioural factors

Cycle of somatosensory amplification – tendency to experience somatic sensations as intense and distressing

SOMATOFORM AND DISSOCIATIVE DISORDERS

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Treatment

Acute somatoform disorders

When patient presents to GP with pain and tests are normal, GP may undertake reattribution, which consists of 3 steps:

Thorough history and physical examination “Broadening the agenda” – explaining that pain may be caused by

psychosocial factors Making the link between psychological factors and physical symptoms

SOMATOFORM AND DISSOCIATIVE DISORDERS

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SOMATOFORM AND DISSOCIATIVE DISORDERS

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SOMATOFORM AND DISSOCIATIVE DISORDERS

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SOMATOFORM AND DISSOCIATIVE DISORDERS

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SOMATOFORM AND DISSOCIATIVE DISORDERS

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SOMATOFORM AND DISSOCIATIVE DISORDERS

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SOMATOFORM AND DISSOCIATIVE DISORDERS

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SUMMARY Historical Approaches to Somatoform and Dissociative

Disorders

Somatoform Disorders DSM-IV-TR Diagnosis Epidemiology Aetiology Treatment

Dissociative Disorders DSM-IV-TR Diagnosis Epidemiology Aetiology Treatment Current Controversies and Challenges