Somatoform DisordersMass Psychogenic IllnessMalingering & Factitious DisordersDissociative DisordersDissociative Disorders

Abnormal PsychologyChapter 8

Feb 5-10, 2009Classes #8-9

Somatoform Disorders Physical symptoms with an absence of

physical reasons for the symptoms No physical damage results from the

disorder These individuals believe that

their illnesses are real

Psychosomatic Disorders

Tension headaches, cardiovascular problems, etc. which cause physical damage

State of mind appears to be causing the illness

Somatoform Disorders

Somatization Disorder (Briquet’s)

Pain Disorder Hypochondriasis Body Dysmorphic Disorder Conversion Disorder

Somatization Disorder

Diagnostic Criteria To be diagnosed a person must have

reported at least the following: Gastrointestinal symptoms (2) Sexual symptoms (1) Neurological symptoms (1) Pain (4 locations) These symptoms cannot be explained

by a physical disorder

Somatization Disorder Sex difference

F > M Primarily a female disorder with about 1% suffering

from this disorder Onset

Usually by age 30 but its seen from childhood on up Familial tendencies

5 to 10 times more common in female first-degree relatives

Genetic links to antisocial personality and alcoholism

A typical scenario… Typically, patients are dramatic and

emotional when recounting their symptoms

They are often described as exhibitionistic and seductive and self-centered

In an attempt to manipulate others, they may threaten or attempt suicide

These patients “doctor-shop”…

Often dissatisfied with their medical care, they go from one physician to another… What would be a recommended route for

these patients to choose insofar a medical/mental health care is concerned???

They usually don’t go and further than their General Practitioner…

Bottom line: Psychologists and psychiatrists rarely

manage the majority of patients with somatoform disorders -- this difficult undertaking falls predominantly on general practitioners

Somatization Disorder Explanations

Psychodynamic Explanation Behavioral (Learning) Explanation Physiological (Biological)

Explanation Cognitive Explanation

Psychodynamic Explanation

They have an unconscious conflict, wish, or need which is converted to a somatic symptom Pent-up emotional energy is converted to a physical

symptom They may have identification with an important

figure who suffered from the symptom They may have the need for punishment because of

an unacceptable impulse directed against a loved one

There may be an unconscious somatized plea for attention and care from these individuals

Learning Explanation A child with an injury quickly learns the

benefits of playing the sick role Reinforced by increased parental

attention and avoidance of unpleasant responsibilities

Physiological Explanation

Genes

Cognitive Explanation They do not accept doctors advice Therefore treatment is difficult

Treatments Really haven’t been successful because patient

usually won’t consider their problem as psychological

In rare cases when individual is receptive to treatment, both psychoanalysis and cognitive treatments have brought improvement

Drug treatments (anti-depressants and anti-anxiety meds) are often used to treat some of the residual symptoms but are not effective in helping with the somatization problems

Complications There are several major complications

to this disorder…

Etiology Unknown

We know it tends to run in families but the cause is unknown at this time

More research is needed for this one

Prognosis Poor

Its usually a lifelong disorder Complete relief of symptoms for any

extended period is rare

Pain Disorder

The patient complains of pain without an identifiable physical cause to explain the symptoms the person is complaining about

Basically, the same as somatization disorder except that pain is the only symptom

Body Dysmorphic Disorder

Preoccupation with an imagined or minor defect in one's physical appearance

It is distinguished from normal concerns about appearance because it is time-consuming, causes significant distress, and impairs functioning

Depression, phobias, and OCD may accompany this disorder

Sex difference: Females > Males Females: breasts, legs Males: genitals, height, and body hair

Symptoms Major concerns involving especially the face

or head but may involve any body part and often shifts from one to another Examples: hair thinning, acne, wrinkles, scars,

eyes, mouth, breasts, buttocks, etc.

“Elise” from First Wives Club

Treatments Cognitive-Behavioral

Exposure is used to treat phobia-like symptoms

Therapy will focus on improving the distorted body image that these people possess

Treatments Physiological

Preliminary evidence that selective serotonin reuptake inhibitors may be helpful but data on drug treatment is limited

 

Treatments Family behavioral treatments can be

useful Support groups if available can also

help 

Prognosis Poor

Since these individuals are reluctant to reveal their symptoms, it usually goes unnoticed for years

Very difficult to treat as they usually insist on a physical cause

More research is needed to determine any effective treatment for this disorder

Hypochondrasis Unrealistic belief that a minor symptom

reflects a serious disease Excessive anxiety about one or two symptoms Examination and reassurance by a physician

does not relieve the concerns of the patient

They believe the doctor has missed the real reason

Hypochondrasis Symptoms adversely affect social and

occupational functioning Diagnosis is suggested by the history

and examination and confirmed if symptoms persist for at least 6 months and cannot be attributed to another psychiatric disorder (such as depression)

Hypochondrasis Gender difference

More common in women than men (I couldn’t find any stats though)

Onset Usually in 30’s But seen in all age groups

Treatments Much research suggests a cognitive-

behavioral combo is best with therapist extremely gentle in his/her questioning the patient’s incorrect beliefs

Prognosis Its not good (perhaps 5% recover) for the

following reasons:

Major Differences between Somatization Disorder and Hypochondrasis

Focus of Complaint Style of Complaint Interaction with Clinician Age Physical Appearance Personality Style

Conversion Disorder Sensory/motor dysfunction in the absence of a

physical basis… Symptoms develop unconsciously and are

limited to those that suggest a neurological disorder Examples: numbness of limbs, paralysis, speech

problems, blindness and hearing loss, difficulty swallowing, sensation of a lump in your throat, difficulty speaking, difficulty walking, etc.

Symptoms are not feigned (as in factitious disorder or malingering)

Individual is often highly dramatic

Conversion Disorder History

Was first studied by the Nancy School of Hypnosis (Nancy, France) and Freud in examinations of hysteria (1880’s)

Onset Tends to be adolescence to adulthood but may occur at

any age Sex Difference

Appears to be "somewhat" more common in women No stats

Prevalence 1% - 3% of general population Tends to occur in less educated, lower socioeconomic

groups

Conversion Disorder: Important Characteristics

Glove anesthesia

Conversion Disorder: Important Characteristics

Doctor Shop They visit many physicians hoping to find

one who will propose a physical treatment for their non-physical problems

La Belle Indifference The tendency of these people to be

relatively unconcerned about their physical problem

Explanations Pure speculation at this point

Treatment Hypnotherapy

The patient is hypnotized and potentially etiologic psychological issues are identified and examined

Narcoanalysis Similar to hypnotherapy except the patient is also

given a sedative to induce a state of semi-sleep Relaxation training

Often combined with cognitive therapy

Prognosis

No treatment is considered very effective

 

Mass Psychogenic Illness

Also referred to as Mass Hysteria Epidemic of a particular manifestation of a

somatoform disorder

Mass Psychogenic Illness

Sex difference: F > M Age Difference: Adolescents and

children seem to be particularly at risk

Mass Psychogenic Illness

Physicians might consider a group sickness as being caused by mass psychogenic illness if: Physical exams and tests are normal Doctors can't find anything wrong with

the group's classroom or office (for example, some kind of poison in the air)

Many people get sick

Mass Psychogenic Illness

Symptoms Include the following: headache, dizziness, nausea,

cramps, coughing, fatigue, drowsiness, sore or burning throat, diarrhea, rash, itching, trouble with vision, anxiety, loss of consciousness, etc.

Treatment Removing patients from the place where the illness

started Separate patients Understand that the illness is real Reassure patients that they will be okay

Complications Do you see any complications here???

Are somatoform disorders real or faked?

Malingering Factitious Disorders

Munchausen Syndrome Munchausen Syndrome by Proxy

Malingering Faking physical illnesses to avoid

responsibility or for economic gain Seek medical care or hospitalization

under false pretenses Once they get what they want they

usually stop all complaining about their alleged problems

Factitious Disorders Here, a person is faking symptoms to

receive the attention and/or sympathy that comes with being sick… Munchausen Syndrome Munchausen Syndrome by Proxy

Munchausen Syndrome (Factitious Disorder By Proxy)

Condition characterized by the feigning of the symptoms of the disease in order to undergo diagnostic tests, hospitalization, or medical or surgical treatment

These people (almost always women) fake serious symptoms in someone close to them (usually a child) to gain attention and sympathy ( a form of child abuse)

 

Munchausen Syndrome by Proxy

Signs and tests

Munchausen Syndrome by Proxy

Treatment Offer parent help rather than accuse them Psychiatric counseling will likely be

recommended Family therapy is often helpful if the husband

is willing  Prognosis

This is often a difficult disorder to treat and often requires years of psychiatric support

Dissociative DisordersDissociative Disorders Dissociative Amnesia Dissociative FugueDissociative Fugue Depersonalization DisorderDepersonalization Disorder Dissociative Identity DisorderDissociative Identity Disorder

Dissociative Amnesia Formerly termed Psychogenic Amnesia.

Name of illness also changed in DSM IV The sudden inability to remember

important personal information or events Usually begins as a response to

intolerable psychological stress Very rare (less than 1%)

Types of Dissociative Amnesia

Localized amnesia The person fails to recall events that occurred during a

particular period of time Selective amnesia

The person can recall some but not all of the events during a certain time frame

Generalized amnesia This lasts throughout a person’s entire life – very rare

Continuous amnesia The inability to recall events subsequent to a specific

time including the present Systemized amnesia

The loss of memory for certain categories of information

Dissociative Amnesia

Treatment Therapy can be useful to help with coping

but is not always needed Often, they become disoriented and may

forget who they are but usually the amnesia vanishes as abruptly as it began

Dissociative Fugue Formerly termed Psychogenic Fugue Name of illness also changed in DSM IV An episode during which an individual

leaves his usual surroundings unexpectedly and forgets essential details about himself and his lives

It is very rare, with a prevalence rate of about 0.2% in the general population

Symptoms Sudden and unplanned travel away from

home together with an inability to recall past events about one's life

Cause Is usually triggered by traumatic and

stressful events, such as wartime battle, abuse, rape, accidents, natural disasters, and extreme violence, although fugue states may not occur immediately

Treatment

Psychoanalysis Cognitive therapy ("creative therapies") Hypnotherapy Medications Family therapy

Depersonalization Disorder

These individuals report feeling detached from their mental processes or body

Occurs in as many as 30% of normal individuals at some time

Only constitutes a disorder if it interferes with a person’s functioning

Cause As with other disorders in this

category, an acute stressor is often the precursor to onset

Symptoms This disorder is characterized by

feelings of unreality, that your body does not belong to you, or that you are constantly in a dreamlike state

Symptoms are most common between 25-44

Treatment The disorder will typically dissipate on

its own after a period of time Therapy can be helpful to strengthen

coping skills

Prognosis Prognosis is very good

Dissociative Identity Disorder

Commonly referred to as Multiple Personality Disorder Very rare: Less than 1%. A person alternates between two or more

distinct personality systems Usually there is a main or basic

personality Sex difference: F > M (9 to 1 ratio)

Symptoms The individual may change from one

personality to another in a matter of a few minutes to several years (shorter time frames are more common)

The personalities are often dramatically different

Complications Sleep disorders

Night terrors and/or sleep walking Alcohol and drug abuse OCD-like rituals Eating disorders Depression High suicide rate

Probably the #1 “Hollywood Disorder”

Important Note Until 1970's extremely rare with few

reported cases (about 100) but since then its prevalence has increased dramatically.

Why this dramatic increase???

Dissociative Identity Disorder

Treatment Psychoanalysis -- try to give therapy

to the main personality who "knows" the others

Prognosis Not good