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