Somatoform and Dissociative Disorders

Somatoform Disorders

Concerns with appearance or functioning of body Absence of medical condition

1. Hypochondriasis

2. Somatization Disorder

3. Conversion Disorder

4. Pain Disorder

5. Body Dysmorphic Disorder

Hypochondriasis

Anxiety over belief one has a disease, without evident cause

Reassurance from doctors no help, in the long-term

Misinterpretation of bodily signals as disease Disorder realized after physician visits

Hypochondriasis - Statistics

Little information Prevalence estimate 3%

Equal in men and women, age groups

Causes of Hypochondriasis

Faulty thoughts/interpretation of physical signs (cognition)

Enhanced sensitivity to illness cues Increased awareness and fright

Family/genetic influences Might be unspecific anxiety Children report symptoms of parents

Causes of Hypochrondriasis

Context of stressful life events - often involving death or illness

Disproportionate incidence of disease in family

Social influence Attention paid to sick relatives

Treatment of Hypochrondriasis

Little information regarding treatment

Cognitive therapy Exposure to symptoms Decreased reassurance

seeking re: symptoms

Stress management program

Somatization Disorder

History of physical complaints, occurring over years

Result in treatment being sought or impairment

4 pain symptoms 2 GI symptoms

1 sexual symptom 1 pseudo-neurologic

symptom Not explained by

medical condition Complaints not

intentionally produced or feigned

Somatization Disorder - Statistics

Rare Continuum 20% estimated

prevalence in primary care settings

Adolescent age of onset

Causes and Treatment

History of family illness Few research studies Genetic link with Antisocial PD Difficult to treat

Conversion Disorder

Physical malfunctioning, suggesting neurological impairment, with no medical cause

E.g., blindness, paralysis Rare Causes - trauma Insight focused treatment, identifying trauma

Pain Disorder

True pain Psychological factors play role May have been original physical cause

Body Dysmorphic Disorder

Preoccupation with imagined defect in appearance

Suicidality common Focused on self and defect (similar to social

anxiety) Can significantly disrupt life

Body Dysmorphic Disorder - Statistics

Difficult to estimate prevalence Chronic course Often seek plastic surgery or other medical

attention 2% of plastic surgery patients?

Little information on cause Link with OCD

Conversion Disorder vs. Malingering

Conversion patients are indifferent to symptoms

Precipitated by stress - 52-93% cases Can function normally, but often unaware of

this ability or sensory input E.g., avoiding objects in visual field

Dissociative Disorders

What is Dissociation?

Derealization: Losing sense of reality of the external world

Common to some degree for everyone (a great example of dimensionality)

Dissociative Disorders

Incredibly puzzling category of mental disorder

Disruption of normal integration of: Consciousness Memory Perception

Separating from identity

Types of Dissociative Disorders

1. Depersonalization Disorder

2. Dissociative Amnesia

3. Dissociative Fugue

4. Dissociative Trance Disorder**

5. Dissociative Identity Disorder

1. Depersonalization Disorder

Feelings of detachment from self “living in a dream” or “going through the motions” Feeling of watching self Can include disconnection from body

Knows this is a feeling, does not believe Common with other disorders (up to 40%) Prevalence unknown Common reaction to stress/burnout

Treating Depersonalization Disorder

No controlled studies; lots of books Supportive + insight-oriented therapy

1. Recognize source2. Reconnect with others & life3. Discuss abuse (if present)

– Medication for certain symptoms (depression)

– Progressive relaxation - increase anxiety?

2. Dissociative Amnesia

Loss of autobiographical memory E.g. the loss of one event memory

Not due to brain damage Usually in response to trauma (which is

forgotten) Spontaneous recovery Prevalence unknown Controversy over existence

3. Dissociative Fugue

Amnesia for past + sudden moving Most are not very long-term

Confusion re: identity Assumption of a new identity May last: hours to months Prevalence estimated: 1 in 500 Usually in response to stressor

Treating Dissociative Amnesia and Fugue

Supportive therapy Usually recover on own Fugue often needs couples/family therapy

Feelings of abandonment At risk of relapse when stressed

Preventive approaches helpful Stress management skills

5. Dissociative Identity Disorder

*Formerly Multiple Personality Disorder Presence of 2+ distinct identities Recurrently control an individual “Alters” & “Host Personality” Alters & Host Personality may/may not be

aware of what is going on

Dissociative Identity Disorder

Alters who are unaware have lapses in memory unaccounted for

Own constellation of behavior, voice tone, gestures

Different reactions to medications, eyeglass prescriptions

May claim to be different in age, gender, race, family history

Alters’ Awareness of Each Other

Mutually amnesic

Mutually cognizant

One-way amnesic

Dissociative Identity Disorder

Preceded by headaches Rare: 1% of general population Few believe prevalence is that high Higher rates of diagnosis?

Better identification? Overused? Iatrogenic?

Dissociative Identity Disorder

Course is unpredictable and varies May be long time b/w treatment & diagnosis

(e.g. 6-7 years) Little insight Chronic or episodic

What Causes Dissociative Disorders?

Trauma (child abuse, etc) Derealization Child abuse as first onset -> coping in

children Common in reporters of child abuse

90% of patients report child abuse

Psychodynamic Perspective

DID results from defense mechanisms Massive repression

Recent work suggests adult stress may also be a risk factor, not just childhood experiences

Trauma & Dissociation

Problem: reports are1. Self-report2. Retrospective

– 1/3 report abuse prior to age 3– Autobiographical memory rarely accurate

before 5– Why no evidence of alters during

childhood?

Causes of Dissociative Disorders

Suggestibility How are people who develop dissociative

disorders different from those who develop PTSD?

Those who develop are better @ dissociating

Suggestibility = personality trait re: ease of accepting ideas proposed by others

Suggestibility

Highly suggestible people: Have more detailed fantasy lives Respond more dramatically to hypnosis

The Autohypnotic Model of DID Select people use self-hypnosis as defense

against emotional trauma Retreat into a trance during trauma that is

protective and provides amnesia

Autohypnotic Model of DID

Trauma(Repeated)

SuggestiblePersonality

Self-hypnosis AltersForm

Flaws in the Autohypnotic Model

Why develop only with abuse? Not war related. Not in bullying Involves a betrayal of trust?

How exactly do alters develop from hypnotic state?

May be little/no evidence of alters until adulthood

Treating DID

No controlled treatment studies Agree: People cannot function well with alters Disagree: How to integrate alters Identify & map alters, then integrate Mapping alters may create more? Others argue - ignore, and will go away

Treating DID

Important to establish trust Usually unsuccessful treatment history Secretive about symptoms Skepticism from other providers

Culture and DID

Rare until late 1980s 1st case 1817, by 1960s lit review = 77

cases 1970s = 300 cases, doubled in 1980s Why the rapid increase? Is it real?

Increase is largely North American Rare in France, where theorists played a

big role

Controversies Surrounding DID

Could Therapists Shape DID? Sociocognitive model of DID (Spanos, 1994)

Symptoms shaped by available info & therapist responses To avoid responsibility? Interest due to rarity Normal social reinforcement Ignore to treat

Controversies Surrounding DID

Recovered Memories Use recovered memory

techniques to assess People repress painful

memories of abuse Therapists encourage

recovery of memory

Evidence Against Recovered Memories

1. Little scientific evidence for repressed memories

2. Can implant false memories in children/adults

3. Techniques used to implant same as therapists use to “recover”

Recovered Memories in Court

Some therapists held liable for harmful techniques

Courts increasingly rejecting recovered memories

Continues to be an intense controversy