Chapter 7 Somatic Symptoms Disorders

And Dissociative Disorders

•Previously called Somatoform Disorders (DSM-IV-TR) •DSM-IV-TR definitions:

• overemphasized that bodily symptoms are medically unexplained

• reinforced mind-body dualism

•DSM-5 definitions:• emphasize distress that accompanies or is in

response to the bodily concerns

Somatic Symptom and Related Disorders

Overview: DSM-IV-TR Somatoform Disorders

DSM-IV-TR Disorder DescriptionPain disorder**term no longer in DSM-5

Psychological factors play a significant role in the onset and maintenance of pain.

Body dysmorphic disorder**DSM-5 OCD condition

Preoccupation with imagined or exaggerated defects in physical appearance.

Hypochondriasis**term no longer in DSM-5

Preoccupation with fears of having aserious illness

Conversion Disorder**now also called Functional Neurological Symptom Disorder (DSM-5)

Sensory or motor symptoms without any physiological cause.

Somatization**term no longer in DSM-5

Recurrent, multiple physical complaints that have no biological basis.

Pain Disorder (DSM-IV-TR)

•No longer diagnosed in DSM-5•Psychological factors are viewed as playing an

important role in the onset, maintenance, and severity of the pain

•Most likely now diagnosed with somatic symptom disorder with predominant pain

Body Dysmorphic Disorder (BDD)

• DSM-5 includes BDD as an OCD condition• preoccupation with an imagined or exaggerated

defect in appearance, frequently in the face• Examples: facial wrinkles, excess facial hair, or the

shape or size of the nose. • Women tend to focus on the skin, hips, breasts,

and legs• Men tend to focus on height, penis size, and

body hair

Hypochondriasis (DSM-IV-TR)

• begins in early adulthood and has a chronic course

• when bodily concerns are present, diagnosed in DSM-5 as: somatic symptom disorder

• When bodily symptoms are not present but person is preoccupied with persistent fears of having a serious medical disease, then diagnosed as: illness anxiety disorder

• the term “hypochondriac” is pejorative, no longer used

Illness (Health) Anxiety

• Cognitive factors are considered central• “catastrophic” misinterpretations of bodily sensations• strong beliefs that unexplained bodily changes are

always a sign of serious illness

Cognitive Model of Health Anxiety

Four contributing factors:1. Critical precipitating

incident 2. Previous experience

of illness and related medical factors

3. Presence of inflexible or negative cognitive assumptions

4. Severity of anxiety

Conversion Disorder

• Also termed Functional Neurological Symptom Disorder (DSM-5)

• Physically healthy people experience sensory or motor symptoms suggesting a neurological illness (although the body organs and nervous system are found to be fine).

• Examples:• Paralysis of arms or legs• Seizures and coordination disturbances• Sensation of prickling, tingling, or creeping on the skin• Insensitivity to pain

• Anaesthesias (loss or impairment of sensations)• Sudden loss or partial loss of vision (blindness or tunnel

vision)• Aphonia (loss of the voice and all but whispered speech)• Anosmia (loss or impairment of the sense of smell)

• Tends to appear suddenly in stressful situations

Hysteria

• Term originally used to describe what are now known as conversion disorders

Conversion Disorder or Malingering?

•Difficult to distinguish • Faking an incapacity in order to avoid a

responsibility is termed malingering

La belle indifférence • Can help differentiate conversion disorder

from malingering• Characterized by a relative lack of concern or

a blasé attitude toward the symptoms • Diagnostic of conversion disorder not

malingering

Factitious Disorder

• Intentionally produce symptoms (usually physical such as pain) or cause self-injury

• In contrast to malingering, the symptoms are less obviously linked to some benefit or secondary gain

Somatization Disorder (DSM-IV-TR)

•Dropped from DSM-5•Mainly diagnosed now as somatic symptom

disorder•Recurrent, multiple somatic complaints, with no

apparent physical cause, for which medical attention is sought

•Prevalence is low in primary care - less than 1% (which is one reason why DSM-5 changes were made)

Somatization Disorder (DSM-IV-TR)(cont’d)

• Symptoms are more pervasive than in hypochondriasis and usually cause impairment

•Considerable overlap with conversion disorder

•Comorbid with anxiety and mood disorders, substance abuse, & several personality disorders

• Specific symptoms may vary across cultures

Theories of Conversion Disorders

•Psychoanalytic Theory• Specific symptoms related to traumatic events• Freud: Unresolved Electra Complex

•Behavioural Theory and Cognitive Factors• Similar to malingering in that the person adopts

the symptom for some additional benefit (secondary gain)

•Social and Cultural Factors • incidence of conversion disorder in the last

century• among people with lower socio-economic status

and from rural areas

Theories (cont.)

•Biological Factors in Conversion Disorder•Evidence is weak•May be some relationship between brain

structure and conversion disorder•Conversion symptoms are more likely to

occur on the left side than on the right side of the body

•Biopsychosocial Model •triggering events (ie abuse), perpetuating

factors (ie life stress), and risk factors (social class)

Therapies for Somatoform Disorders

•Little controlled research on psychological treatments because somatoform disorders are less commonly seen in psychological practices than other conditions• tend to undergo costly medical investigations

and medical treatments than other disorders

•Comorbid with anxiety and depression • See treatment sections for these disorders

•Cognitive-behavioural approaches

Dissociative Disorders – DSM-5

•Characterized by disruptions of consciousness, memory, and identity

•Dissociative Amnesia – memory loss following a stressful experience

•Depersonalization/derealization disorder – altered experience of the self

•Dissociative Identity Disorder – at least two different (alternative) ego states (alters)

•Other Specified Dissociative Disorder

Dissociative Amnesia

• Person unable to recall important personal information, usually after some stressful episode. • Information not permanently lost, but cannot be

retrieved during the episode of amnesia• Most often memory loss involves all events during a

limited period of time

• Total amnesia• Patient does not recognize relatives and friends, but

retains the ability to talk, read, and reason • Retains talents and previously acquired knowledge

•Amnesic episode may last several hours or as long as several years. • Usually disappears as suddenly as onset

Dissociative Fugue

•Previously (DSM-IV-TR) was considered a category, now it is specific form of dissociative amnesia.

•Memory loss more extensive in dissociative fugue than in dissociative amnesia. • Person becomes totally amnesic and suddenly

leaves home and work and assumes a new identity.

•Fugues typically occur after a person has experienced some severe stress

Depersonalization/Derealization Disorder

• Person’s perception or experience of the self is disconcertingly and disruptively altered• Unusual sensory experiences• May have ‘out of body’• May feel mechanical (as if they or others are

‘robots’)

• Typically triggered by stress•Usually begins in adolescence and has a

chronic course•Comorbid with personality disorders, anxiety

disorders, and depression

•DSM-5 changed Depersonalization criteria to include Derealization, which is a sense of detachment from situational context

Dissociative Identity Disorder (DID)•Diagnosis requires that a person have at

least two separate ego states (called ‘alters’) that exist independently of each other

•Alters emerge and are in control at different times• Usually one primary ego state and two to four

alters at time of diagnosis • Treatment sought by the primary alter• Gaps in memory occur in all cases• Existence of alters must be long-lasting and cause

considerable disruption in one’s life • Often accompanied by headaches, substance

abuse, phobias, hallucinations, suicide attempts, sexual dysfunction, and self-abusive behaviour and other dissociative symptoms such as amnesia and depersonalization

DID (cont.)

•Presumably begins in childhood, but rarely diagnosed until adulthood

•More common in women than in men•Comorbid with depression, borderline

personality disorder, and somatization disorder• In one study 90% had a history of suicidal

tendencies, depression, recurring headaches, and sexual abuse

• Another study is suspecting poor attachment due to exposure of frightening or chaotic behaviour from caregiver

•Diagnosis of DID is a very controversial

DID Case exampleHerschel Walker – Football star

Etiology of Dissociative Disorders

• Etiology of DID• Psychoanalytic & behavioural perspectives:

Dissociation as an avoidance response that protects the person from memories of traumatic experiences

• 2 major theories• Result of severe physical or sexual abuse • Enactment of learned social roles

Treatments of Dissociative Disorders

• Psychoanalytic Treatment • Goal: to lift repression of traumatic events

• Treatments for PTSD trauma applied to dissociative disorders

• Treatment of DID • Hypnosis used for ‘age regression’ • Goal: integration of the several personalities

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