chapter 7 somatic symptoms disorders and dissociative disorders
TRANSCRIPT
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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