chapter 8: somatic symptoms and dissociative disorders

MILD DISSOCIATIVE AND SOMATIC - people with somatic symptom-related

SYMPTOMS disorders often have trouble identifying their

- people who constantly complained about emotions and describing them directly

being sure they had a serious illness even - affected patients have no control over their

though medical tests failed to show anything symptoms including paralysis or pain; not

wrong intentionally faking symptoms or attempting to

deceive others and they genuinely believe

4 DISORDERS IN THE SOMATIC SYMPTOM something is terribly wrong with them to the

AND RELATED DISORDERS CATEGORY: point that they frequently engage in illness
behavior that is dysfunctional, such as seeking

additional medical procedures or diagnostic

tests when the physician fails to find anything
1.) SOMATIC SYMPTOM DISORDER
physically wrong with them; and are likely to
think something was missed and therefore seek
help from another physician, leading to
needlessly high medical bills due to unnecessary
tests, hospitalizations, and even surgeries
- people with somatic symptom disorders tend
to have a cognitive style that leads them to be
- soma means body
hypersensitive to their bodily sensations and
- also called as somatoform disorder
they experience these sensations as intense,
- lie at the interface between abnormal
disturbing, and highly aversive
psychology and medicine
- they tend to think catastrophically about their
- a group of conditions that an individual is
symptoms, often overestimating the medical
experiencing chronic somatic symptoms that are
severity of their condition, and often view their
distressing and experiencing physical symptoms
physicians as incompetent and uncaring
combined with abnormal thoughts, feelings, and
behaviors in response to those symptoms
IN DSM-5, IT WAS EXPLAINED THAT MEDICALLY
UNEXPLAINED SYMPTOMS ARE STILL A KEY
PART OF SOME DISORDERS SUCH AS
CONVERSION DISORDER
- In the past, the diagnosis required evidence
that the symptoms were medically unexplained;
but, now instead, the focus in DSM-5 is on there
being at least one of the following three
features, and symptoms have to have persisted
for at least 6 months
1 OF THE FOLLOWING 3 FEATURES:
* disproportionate and persistent thoughts
about the seriousness of one’s symptoms
* persistently high level of anxiety about health
or symptoms
* excessive time and energy devoted to these
symptoms or health concerns
FEAR THAT A BODILY SENSATION
SIGNIFIES ILLNESS IS LIKELY TO HAVE
TWO BEHAVIORAL CONSEQUENCES
* the person may assume the role of being sick
and avoid work and social tasks, and this can
intensify symptoms by limiting exercise and
other healthy behaviors
* the person may seek reassurance from
doctors and from family members, and this
help-seeking behavior may be reinforced if it
results in the person getting attention or
sympathy
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES OF SSD
- patients with somatic symptom disorder are
usually seen in medical clinics
- more likely to be female, nonwhite, and less
educated than are people with symptoms that
have an obvious medical basis
- may begin or intensify after some conflict or
stress
• HIGH LEVELS OF FUNCTIONAL IMPAIRMENT
ARE COMMON, AS IS COMORBID
PSYCHOPATHOLOGY ESPECIALLY DEPRESSION
AND ANXIETY
CAUSAL FACTORS OF SSD
>> TWINS AND GENETICS
- no concordance among twins for somatic
symptom disorder, and it’s not heritable
• PEOPLE RECEIVE DISABILITY PAYMENTS BASED
ON HOW MUCH SYMPTOMS INTERFERE WITH
THEIR DAILY ACTIVITIES
- people receive disability payments based on
how much symptoms interfere with their daily
activities
 - involvement of these regions in experiences of
>> NEUROBIOLOGICAL FACTORS THAT physical and emotional pain may help explain
INCREASE AWARENESS OF AND DISTRESS why emotions and depression can intensify
OVER SOMATIC SYMPTOMS   experiences of pain

>> COGNITIVE BEHAVIORAL FACTORS

THAT INCREASE AWARENESS OF AND
DISTRESS OVER SOMATIC SYMPTOMS 

- focus on brain regions activated by unpleasant

body sensations
- pain and uncomfortable physical sensations
pink boxes are
such as heat, increase activity in regions of the relevant to
understanding how
brain called anterior insula and the anterior a person might
initially develop a
cingulate somatic symptom

- regions have strong connections with the

somatosensory cortex
blue boxes are
insula controls autonomic functions through the regulation of the relevant for
sympathetic & parasympathetic systems. It has a role in regulating the understanding
immune system. it also has an important role in pain experience and reactions to a
the experience of a number of basic emotions, including anger, fear, somatic symptom
disgust, happiness, and sadness
SOMATOSENSORY CORTEX
- a region of the brain involved with processing
bodily sensations

• HEIGHTENED ACTIVITY IN THESE REGIONS IS COGNITIVE BEHAVIORAL MODELS

RELATED TO GREATER PROPENSITY FOR - focus on the mechanisms that could contribute

SOMATIC SYMPTOMS AND MORE INTENSE to the excessive focus on and anxiety over

RATINGS OF THE UNPLEASANTNESS OF A health concerns

STANDARDIZED PAINFUL STIMULUS

- including anterior insula, anterior cingulate ONCE A SOMATIC SYMPTOM DEVELOPS,

that has strong connections with somatosensory TWO COGNITIVE VARIABLES APPEAR

cortex IMPORTANT:

- depression, anxiety and somatic symptoms are 1.) ATTENTION TO BODY SENSATIONS

related to anterior cingulate - people with excessive distress about their

- experiences of emotional pain, such as somatic symptoms may automatically focus on

remembering a relationship breakup, can also cues of physical health problems

activate the anterior cingulate and the anterior

insula
2.) INTERPRETATION OF THOSE • THE OLD DISORDERS OF HYPOCHONDRIASIS,
SENSATIONS (ATTRIBUTIONS) SOMATIZATION DISORDER, AND PAIN DISORDER
- an attribution is a person’s idea about why HAVE ALL NOW DISAPPEARED FROM DSM-5
something is happening
- people prone to worries about their health
also demonstrate an attributional style that
involves interpreting physical symptoms in the
worst possible way

• THE EXACT FORM OF THE COGNITIVE BIAS

MAY VARY, BUT ONCE THESE NEGATIVE
THOUGHTS BEGIN, THE RESULTANT ELEVATIONS
OF ANXIETY AND CORTISOL MAY EXACERBATE
SOMATIC SYMPTOMS AND DISTRESS OVER
THOSE SYMPTOMS
- people who would in the past have been
diagnosed with any one of these disorders will
now be diagnosed with a somatic symptom
disorder

DIFFERENCE BETWEEN SOMATIC HYPOCHONDRIASIS

SYMPTOM DISORDERS AND PANIC

DISORDER

PD SSD

- are likely to overreact to - the person believes the

physiological symptoms
- the person often believes
that the symptoms are a
sign of an immediate
threat. ex. a heart attack
- focuses on symptoms
that will actually become
worse as they become
more anxious. ex. fast
heart rate, shortness of
breath, or sweaty palms
symptoms are a sign of an
underlying long-term
disease
- patient with somatic
symptom disorder do not
worsen physical symptoms
as they get more anxious,
instead, their cognitive
bias and negative
interpretations about
diseases, increases
- ex. increase the size of a
spot on the skin by
misconstruing it as cancer
- 75 percent of people previously diagnosed
with hypochondriasis will be diagnosed with
somatic symptom disorder in DSM-5
- the person is preoccupied either with fears of
contracting a serious disease or with the idea
that of having that disease even though they do
not
- these very distressing preoccupations are
thought to all be based on a misinterpretation
of one or more bodily signs or symptoms. ex.
being convinced that a slight cough is a sign of
lung cancer
- the decision that a complaint is
hypochondriacal and is based on a
misinterpretation of bodily signs or symptoms
can only be made after a thorough medical MAJOR CHARACTERISTICS OF

evaluation has failed to find a medical condition HYPOCHONDRIASIS

that could account for the signs or symptoms
- another feature: the person cannot be
reassured by the results of a medical evaluation;
the fear or idea of having a disease persists
despite lack of medical evidence; these
individuals are sometimes disappointed when
no physical problem is found
- condition has to persist for at least 6 months
for the diagnosis to be made so as to not
diagnose relatively transient health concerns
- tend to be highly preoccupied with bodily
functions (heart beats or bowel movements), or
with minor physical abnormalities (a small sore
or an occasional cough), or with vague and
ambiguous physical sensations such as a tired
heart or aching veins
- diagnoses they make for themselves include
cancer, exotic infections, AIDS, and numerous
other diseases they attribute these
symptoms to a particular
disease and often have
intrusive thoughts about it

• THE RELATIONSHIPS THEY HAVE WITH THEIR

DOCTORS ARE OFTEN MARKED BY CONFLICT
AND HOSTILITY
- since people with hypochondriasis do not
believe that they do not have an illness because
they are sincere in their conviction that the
symptom they detect represent real illness
- they are not faking symptoms for external
rewards or what we called malingering

• INDIVIDUALS WITH HYPOCHONDRIASIS OFTEN

ALSO SUFFER FROM MOOD DISORDERS, PANIC
DISORDER, OR OTHER TYPES OF SOMATIC
SYMPTOM DISORDER

PREVALENCE, AGE OF ONSET, AND GENDER

DIFFERENCES OF HYPOCHONDRIASIS
- occurs about equally often in men and women
and can start at almost any age; although early
adulthood is the most common age of onset CAUSAL FACTORS OF HYPOCHONDRIASIS

- regarded as a persistent disorder if left 1.) COGNITIVE-BEHAVIORAL VIEWS

untreated, although its severity can fluctuate - these have as a central tenet that it is a

over time disorder of cognition and perception

- misinterpretations of bodily sensations are
currently a defining feature of the syndrome,
but in the cognitive-behavioral view these
misinterpretations also play a causal role
- an individual’s past experiences with illnesses
(oneself, others, and mass media) lead to the
development of a set of dysfunctional
assumptions about symptoms and diseases that
may predispose a person to developing
hypochondriasis ex. “Bodily changes are usually a
sign of serious disease, because
- people with hypo every symptom has to have an
identifiable physical cause”
have an attentional
bias for illness related information since they
focus to excessive attention on symptoms that
they perceive as more dangerous than they
really are and judge a particular disease to be
more likely or dangerous than it really is
- seem to believe that being healthy means
being completely symptom-free, perceive their
probability of being able to cope with the illness
as extremely low, and see themselves as weak
and unable to tolerate physical effort or exercise
• THIS CREATE A VICIOUS CYCLE IN WHICH
THEIR ANXIETY ABOUT ILLNESS AND SYMPTOMS
RESULTS IN PHYSIOLOGICAL SYMPTOMS OF
ANXIETY, WHICH THEN PROVIDE FURTHER FUEL
FOR THEIR CONVICTIONS THAT THEY ARE ILL
2.) LEARNED BEHAVIOR
- most of us learn as children that when we are
sick special comforts and attention are provided
and that we may be excused from a number of
responsibilities
- people with hypochondriasis also tend to have
an excessive amount of illness in their families
while growing up, which may lead to strong
memories of being sick or in pain
TREATMENT OF HYPOCHONDRIASIS  complaints, taking them as signs of serious
* COGNITIVE-BEHAVIORAL TREATMENT
- it can be a very effective treatment for
hypochondriasis
- cognitive components of this treatment
approach focus on assessing the patient’s beliefs
about illness and modifying misinterpretations
of bodily sensations
- behavioral techniques include having patients
induce innocuous symptoms by intentionally
focusing on parts of their body so that they can
learn that selective perception of bodily
sensations plays a major role in their symptoms
- directed to engage in response prevention by
not checking their bodies as they usually do and
by stopping their constant seeking of
reassurance
- is relatively brief (6 to 16 sessions) and can be
delivered in a group format
SOMATIZATION DISORDER #Impairment
- is characterized by many different physical
complaints
- to qualify for the diagnosis, these had to begin
before age 30, and last for several years; and
not be adequately explained by independent
findings of physical illness or injury
- had to have led to medical treatment or to
significant life impairment
- tend to see bodily sensations as somatic
symptoms
- they tend to catastrophize about minor bodily
physical illness, and to think of themselves as
physically weak and unable to tolerate stress or
physical activity
PREVALENCE, AGE OF ONSET, AND GENDER
- runs in families and that there is a familial
linkage between antisocial personality disorder
in men and somatization disorder in women
(antisocial personality and somatization

DIFFERENCES OF SOMATIZATION D.
- begins in adolescence and 3 to 10 times more
common in women than men
- tends to occur more among less educated
individuals and in lower socioeconomic classes
- co-occurred with other disorders including
major depression, PD, phobic disorders, & GAD

SOMATIZATION DISORDER
DSM-IV-TR DSM-5

- must have 4 pain - in DSM-5 the long and

symptoms, 2 complicated symptom
gastrointestinal count is no longer disorders tend to co-occur)
symptoms, 1 sexual required and
- one possibility is that both antisocial
symptom and 1 somatization disorder
personality and somatization disorders are
neurological-type is now considered to be
linked through a common trait of impulsivity
symptom; patient had just another variant of
to have experienced at somatic symptom
least 8 out of 33 disorder TREATMENT OF SOMATIZATION D.

specified symptoms >> COGNITIVE-BEHAVIORAL TREATMENTS

- hypochondriasis and - it is no longer
- may be quite helpful and that general
somatization disorder necessary for us to be
practitioners can be educated in how to better
are different and concerned about
manage and treat somatization patients and be
separated disorders whether somatization
less frustrated by them
disorder and
hypochondriasis are
really two different and >> COGNITIVE BEHAVIORAL THERAPY
distinct disorders COMBINATION WITH EFECTIVE TREATMENT
WITH PHYSICIAN
- one moderately effective treatment involves
identifying one physician who will integrate the
patient’s care by seeing the patient at regular
visits and by providing physical exams focused
CAUSAL FACTORS OF SOMATIZATION D. on new complaints
>> FAMILY STUDIES
- the physician avoids unnecessary diagnostic
testing and makes minimal use of medications
or other therapies
- combined with cognitive-behavioral therapy
that focuses on promoting appropriate
behavior, such as better coping and personal
adjustment, and discouraging inappropriate
behavior such as illness behavior and
preoccupation with physical symptoms
PAIN DISORDER #Factitious #Impairment
- characterized by persistent and severe pain in
one or more areas of the body that is not
intentionally produced or feigned
- although a medical condition may contribute
to the pain that is very real and can hurt as
much as pain that comes from other sources,
but pain is always, a subjective experience that
is private and cannot be objectively identified by
others, and psychological factors are judged to
play an important role and influence all forms of
pain, making pain impossible to assess with
pinpoint accuracy
- pain disorder may be acute which has a
duration of less than 6 months or chronic which
has a duration of over 6 months
- are often unable to work and they sometimes
go on disability or to perform some other usual
daily activities
- their resulting inactivity including an avoidance
of physical activity and social isolation may lead
to depression and to a loss of physical strength
and endurance
- the behavioral component of pain is quite
malleable in the sense that it can increase when
it is reinforced by attention, sympathy, or
avoidance of unwanted activities
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES OF PAIN DISORDER
- quite common among patients at pain clinics
- diagnosed more frequently in women than in
men and is very frequently comorbid with
anxiety or mood disorders, which may occur
first or may arise later as a consequence of the
pain disorder
TREATMENT OF PAIN DISORDER
>> COGNITIVE-BEHAVIORAL TECHNIQUES
- widely used in the treatment of both physical
and more psychological pain syndromes
>> TREATMENT PROGRAMS
- include relaxation training, support and
validation that the pain is real, scheduling of
daily activities, cognitive restructuring, and
reinforcement of no-pain behaviors
- tend to show substantial reductions in
disability and distress, although changes in the
intensity of their pain tend to be smaller in
magnitude
MEDICATIONS OF PAIN DISORDER
* ANTIDEPRESSANT MEDICATIONS
- especially the tricyclic antidepressants and
certain SSRIs
- shown to reduce pain intensity in a manner
independent of the effects the medications may
have on mood
2.) ILLNESS ANXIETY DISORDER
- new to DSM-5; people have high anxiety about
having or developing a serious illness
- this anxiety is distressing and/or disruptive,
involves fears of having major medical illness
but in the absence of somatic symptoms,
however, sometimes there are very few/mild
somatic symptoms
• PEOPLE WITH HYPOCHONDRIASIS WILL BE
DIAGNOSE AS ILLNESS ANXIETY DISORDER IN
DSM-5 IF IT HAS MINIMAL OR NO SOMATIC
SYMPTOMS. HOWEVER, WHEN PEOPLE WITH
HYPOCHONDRIASIS HAVE SOMATIC SYMPTOMS,
THE PERSON WILL BE DIAGNOSE AS SOMATIC
SYMPTOMS DISORDER
TREATMENT OF ILLNESS ANXIETY
DISORDER
>> COGNITIVE BEHAVIORAL TREATMENT
- was as effective as an antidepressant in
reducing illness anxiety symptoms
- also known as the beautiful
indifference
- seeming lack of concern in the
way patient describe what is wrong
such as partial paralysis,
blindness, deafness, and
pseudo seizures
- 25% of people who would have been
diagnosed with hypochondriasis in DSM-IV will
be diagnosed with illness anxiety disorder in
DSM-5
3.) CONVERSION DISORDER
- also known as Functional Neurological
Symptom Disorder
- one of the most intriguing and baffling patterns
in psychopathology since it involves a pattern in
which symptoms or deficits affecting the senses
or motor behavior strongly suggest that the
patient has a medical or neurological condition
- la belle indifference is one of the criteria in
conversion disorder but was dropped later on
- it becomes apparent that the pattern of
symptoms or deficits cannot be fully explained
by any known medical condition
- person is not intentionally producing or faking
to, Freud, it was one of
the symptoms, rather, psychologicalseveral
factorsdisorders
are that
were grouped together
often judged to play an important role because
under the term hysteria
symptoms usually either start or are
exacerbated by preceding emotional or
interpersonal conflicts or stressors • PATIENTS WITH CONVERSION
- Freud suggested that most people w/ DISORDER SHOW HOW FUNCTIONAL
conversion disorder showed very little of the A CONVERSION DISORDER MAY BE IN
anxiety and fear that would be expected in a THE OVERALL LIFE CIRCUMSTANCES OF A
person with a paralyzed arm or loss of sight PATIENT DESPITE ITS EXACTING A CERTAIN COST

IN ILLNESS OR DISABILITY

CONVERSION HYSTERIA
- typically occurred under highly stressful
- Freud used this term since he believed that the
combat conditions and involved men who would
symptoms were an expression of repressed the unconscious conflict
that a person felt about ordinarily be considered stable
sexual energy
his or her repressed
- most common in women
- the repressed anxiety threatens to become sexual desires
- begin between early
conscious, so it is unconsciously converted into
adolescence and early adulthood
a bodily disturbance, thereby allowing the
- often resolves within 2 weeks if the stressor is
person to avoid having to deal with the conflict
removed, although it commonly recurs
- ex. a person’s guilty feelings about the desire
- most common conversion symptoms among
to masturbate might be solved by developing a
soldiers is paralysis of the legs that enabled a
paralyzed hand
soldier to avoid an anxiety-arousing combat
- Freud also thought that the reduction in primary gain is a
situation without being labeled a coward
anxiety and intrapsychic conflict was the continued escape or
avoidance of a
or being subject to court-martial
primary gain that maintained the condition stressful situation
- today, it is most likely to occur in rural
- patients often had many sources of secondary
people from lower socioeconomic
gain
refer to any external circumstance,
such as attention from loved ones circles who are medically unsophisticated.
or financial compensation, that
ex. serious motor weakness and wasting
PREVALENCE, AGE OF would tend to reinforce the
maintenance of disability
symptoms in five 9- to 13-year-old girls
ONSET, AND GENDER
living in a small, poor, rural Amish community
DIFFERENCES OF CONVERSION DISORDER

- relatively common in civilian and especially in had experienced substantial

psychosocial stressors including
military life; was the most frequently diagnosed behavioral problems,
dysfunctional family dynamics,
psychiatric syndrome among soldiers in word and significant community stress
from a serious local church crisis
war 1 and 2
4/5 showed improvement over 3
months because their caregivers
were to stick with one doctor,
- conversion disorder frequently occurs along
with other disorders, especially major
depression, anxiety disorders, and other forms
of somatic symptom or dissociative conditions
4 CATEGORIES OF SYMPTOMS OF CD
(1) SENSORY SYMPTOMS OR DEFICITS
- involve almost any sensory modality, and it can
often be diagnosed as a conversion disorder
because symptoms in the affected area are
inconsistent with how known anatomical
sensory pathways operate
- sensory symptoms or deficits are most often in
the visual system especially blindness and
tunnel vision, in the auditory system especially
(2) MOTOR SYMPTOMS OR DEFICITS
- motor conversion reactions also cover a wide
range of symptoms; ex. conversion paralysis
CONVERSION PARALYSIS
- is usually confined to a single limb such as an
arm or a leg, and the loss of function is usually
selective for certain functions
- ex. a person may not be able to write but may
be able to use the same muscles for scratching,
or a person may not be able to walk most of the
time but may be able to walk in an emergency
such as a fire
APHONIA

deafness, or in the sensitivity to feeling

especially the anesthesia
conversion deafness- not being
able to hear and yet orients
upon hearing his /her own name
conversion blindness- he or
she cannot see and yet can
often navigate about a room
without bumping into
furniture or other objects

• CONVERSION BLINDNESS AND DEAFNESS

RECEIVES INFORMATION BUT SCREENED FROM
CONCIOUSNESS - a person is able

- In general, the evidence supports the idea that to talk only in a whisper although he or she can

the sensory input is registered but is somehow usually cough in a normal manner

screened from explicit conscious recognition

(explicit perception) ORGANIC LARYNGEAL PARALYSIS
- both the cough and the voice are affected

ANESTHESIAS
- the person loses her or his sense of feeling in a GLOBUS HYSTERICUS

part of the body

GLOVE ANESTHESIA
- in which the person cannot feel anything on
the hand in the area where gloves are worn,
although the loss of sensation usually makes no
anatomical sense - another common motor symptom
- is difficulty swallowing or the sensation of a
lump in the throat
(3) CONVERSION SEIZURES
- another relatively common form of conversion
symptom
- involve pseudoseizures
PSEUDOSEIZURES
- which resemble epileptic seizures in some
ways but can usually be fairly well differentiated
via modern medical technology
- ex. patients with pseudoseizures do not show
any EEG/electroencephalogram abnormalities
and do not show confusion and loss of memory
afterward, which epileptic seizures do
- often show excessive thrashing (move
violently, hit something hard and repeatedly)
about and writhing (twisting, squirming) not
seen with true seizures, and they rarely injure
themselves in falls or lose control over their
bowels or bladder, as patients with true seizures
frequently do
(4) A MIXED PRESENTATION OF THE
FIRST THREE CATEGORIES
IMPORTANT ISSUES IN DIAGNOSING
CONVERSION DISORDER 
- medical tests especially brain imaging has
become increasingly sophisticated, the rate of
misdiagnoses has declined substantially
SEVERAL OTHER CRITERIA ARE ALSO
COMMONLY USED FOR DISTINGUISHING
BETWEEN CONVERSION DISORDERS AND
TRUE NEUROLOGICAL DISTURBANCE
>> THE FREQUENT FAILURE OF THE
DYSFUNCTION TO CONFORM CLEARLY TO
THE SYMPTOMS OF THE PARTICULAR DISEASE
OR DISORDER SIMULATED
- ex. little or no wasting away or atrophy of a
paralyzed limb occurs in conversion paralyses
>> THE SELECTIVE NATURE OF THE
DYSFUNCTION
- ex. in conversion blindness the affected
individual does not usually bump into people or
objects, and paralyzed muscles can be used for
some activities but not others
>> UNDER HYPNOSIS OR NARCOSIS (A
SLEEPLIKE STATE INDUCED BY DRUGS)
- the symptoms can usually be removed, shifted,
or reinduced at the suggestion of the therapist
TREATMENT OF CONVERSION DISORDER 
>> BEHAVIORAL APPROACH
- it is known that some hospitalized patients
with motor conversion symptoms have been
successfully treated with this
- including specific exercises & reinforcements
- in a study, all had regained their ability to
move or walk in an average of 12 days
SPECIFIC EXERCISES
- are prescribed in order to increase movement
or walking
REINFORCEMENTS
- including praise and gaining privileges
- are provided when patients show
“improvements”
• ANY REINFORCEMENTS OF ABNORMAL
MOTOR BEHAVIORS ARE REMOVED IN ORDER
TO ELIMINATE ANY SOURCES OF SECONDARY
GAIN (external reward such as attention)
>> COGNITIVE-BEHAVIOR THERAPY
- used to successfully treat psychogenic seizures
>> HYPNOSIS COMBINED WITH OTHER
PROBLEM-SOLVING THERAPIES
• HYPNOSIS OR ADDING HYPNOSIS TO OTHER
THERAPEUTIC TECHNIQUES, CAN BE USEFUL
4.) FACTITIOUS DISORDER
- people do deliberately and consciously feign
psychological symptoms, disability or illness that
also placed in somatic symptoms and related
disorders category in DSM-5
- the person intentionally produces
psychological or physical symptoms or both
- the person’s goal is to obtain and maintain the
benefits that playing the “sick role” even to the
extent of undergoing repeated hospitalizations
- benefits includes attention and concern of
family and medical personnel; but there are no
tangible external rewards
- frequently these patients surreptitiously alter
their own physiology by taking drugs, in order to
simulate various real illnesses
- they may be at risk for serious injury or death
and may even need to be committed to an
institution for their own protection
MALINGERING
- the person is intentionally producing or grossly
exaggerating physical symptoms and is
motivated by external incentives such as
avoiding work or military service or evading
criminal prosecution
MUNCHAUSEN’S SYNDROME
- In the past, this is the term for severe and
chronic forms of factitious disorder with
physical symptoms
- where the general idea was that the person
had some kind of hospital addiction or
professional patient syndrome
• CONVERSION DISORDER/ OTHER SOMATIC
SYMPTOMS AND DELIBERATE FAKING SIMILAR
WITH MALINGERING AND FACTITIOUS
DISORDER ARE DISTINCT FROM ONE ANOTHER
- malingering and factitious disorder consciously
perpetrating frauds by faking the symptoms of
diseases or disabilities and this fact is often
reflected in their demeanor
- individuals with conversion disorders (as well
as with other somatic symptom disorders) are
not consciously producing their symptoms feel
themselves to be the “victims of their
symptoms,” and are very willing to discuss
them, often in excruciating detail
TREATMENT OF SOMATIC SYMPTOM AND
RELATED DISORDER
>> INNOVATIVE PROGRAMS #Trust
- involve coaching general practitioners and
their treatment teams to provide care for
people with somatic symptom disorders
- goal is to establish a strong relationship that
allows the person to have a sense of trust and
comfort, so that the patient will feel more
reassured about their health
• THOSE WHO RECEIVED HIGH LEVELS OF
SUPPORT SHOWED MORE IMPROVEMENT IN
SYMPTOMS AND QUALITY OF LIFE OVER THE
NEXT 6 WEEKS
- compared to those who received low levels of
support
• BETTER TO WORK WITH PATIENTS ON WAYS
TO IMPROVE THEIR LIVES THAN ON DEBATING
THEM ABOUT THE SOURCE OF THEIR
SYMPTOMS
>> OTHER HEALTH CARE SYSTEM
INTERVENTIONS
- involve informing physicians when a patient
appears to be an intensive user of health care
services so that they can minimize the use of
diagnostic tests and medications
- types of interventions with physicians can
reduce the frequency of health care services
>> PSYCHODYNAMIC TREATMENT
- found to be effective in alleviating the physical
symptoms of somatic symptom-related
disorders in the short term
>> COGNITIVE BEHAVIORAL STRATEGIES
- developed to address the recurrent somatic
symptoms and distress observed in these
disorders
- including relaxation training to improve
somatic symptoms
DIFFERENT TECHNIQUES OF CBT:
(1) identify and change the emotions that
trigger their somatic concerns
(2) change their cognitions regarding their
somatic symptoms
(3) change their behaviors so they stop playing
the role of a sick person and gain more
reinforcement for engaging in other types of
social interactions
COGNITIVE STRATEGIES/INTERVENTIONS
- involve training people to pay less attention to MEDICATIONS OF SOMATIC SYMPTOM

their body AND RELATED DISORDER

- might help people identify and challenge >> ANTIDEPRESSANTS
negative thoughts about their bodies - can reduce the pain symptoms of somatic
- patients may learn to reframe their experience symptom disorder
of a somatic symptom, such as pain - low doses of some antidepressant drugs, most
especially imipramine
(Tofranil), are superior to a
placebo in reducing chronic
pain and related distress
BEHAVIORAL TECHNIQUES - reduce pain even when given in dosages too
- might help people resume healthy activities low to alleviate the associated depression
and rebuild a lifestyle that has been damaged
by too much focus on illness-related concerns
- techniques such as exposure and cognitive
restructuring could address interpersonal
fears, which might help lessen somatic
complaints
- assertiveness training and social skills
training can also help to approach and talk to
people, to maintain eye contact, to give
DISSOCIATIVE DISORDERS

compliments, to accept criticism, and to make - are a group of conditions involving disruptions

requests in a person’s normally integrated functions of

consciousness, memory, identity, or percept

>> PSYCHOEDUCATION PROGRAMS - Included here are some of the more dramatic

- can help patients recognize links between their phenomena in the entire domain of

negative moods and somatic symptoms psychopathology

- people with dissociative disorders, normally

>> FAMILY THERAPY integrated and well-coordinated multichannel

- could help change reliance on playing the role quality of human cognition becomes much less

of a sick person coordinated and integrated to the point that the

- able to change relationships to support her affected person may be unable to access

movement away from a focus on physical information that is normally in the forefront of

complaints consciousness, such as his or her own personal

- therapist might use operant conditioning identity or details of an important period of time

approaches with family or friends to reduce the in the recent past

amount of attention they give the person’s - similar with somatic symptom disorders, it

somatic symptoms appears mainly to be ways of avoiding anxiety

and stress (by pathologically dissociating) and of
managing life problems that threaten to
overwhelm the person’s usual coping resources
by escaping from his or her own
autobiographical memory or personal identity
- similar again with somatic, it enables the
individual to deny personal responsibility for his
or her unacceptable wishes or behavior
PHENOMENA IN THE DOMAIN OF
PSYCHOPATHOLOGY
>> people who cannot recall who they are or
where they may have come from
>> people who have two or more distinct
identities or personality states that
alternately take control of the individual’s
behavior
DISSOCIATION
- refers to the human mind’s capacity to engage
in complex mental activity in channels split off
from, or independent of, conscious awareness
- was first promoted over a century ago by the
French neurologist Pierre Janet
- there is nothing inherently pathological about
dissociation itself; only becomes pathological
when the dissociative symptoms are perceived
as disruptive, invoking a loss of needed
information, as producing discontinuity of
experience or as recurrent, jarring involuntary
intrusions/intruding into executive functioning
and sense of self
MILD DISSOCIATIVE SYMPTOMS
- occur when we daydream or lose track of what
is going on around us, when we drive miles
beyond our destination without realizing how
we got there, or when we miss part of a
conversation, we are engaged in
SEVERAL TYPES OF PATHOLOGICAL
DISSOCIATION
(1) DEPERSONALIZATION/
DEREALIZATION DISORDER
- 2 of the more common kinds of dissociative
symptoms; sometimes occur during panic
attacks
- but when episodes of depersonalization or
derealization become persistent and recurrent
and interfere with normal functioning,
depersonalization/derealization disorder may be
diagnosed
- people have persistent or recurrent
experiences of feeling detached from and like an
outside observer of their own bodies and
mental processes; they may even feel they are,
for a time, floating above their physical bodies,
which may suddenly feel very different, as if
drastically changed or unreal
• 50-74% OF US HAVE SUCH EXPERIENCES IN
MILD FORM OF DEPERSONALIZATION/
DEREALIZATION AT LEAST ONCE IN OUR LIVES,
USUALLY DURING OR AFTER PERIODS OF
SEVERE STRESS, SLEEP DEPRIVATION, OR
SENSORY DEPRIVATION
- sensory deprivation pertains to deprived of
normal external stimuli such as sight and sound
for an extended period of time
DEREALIZATION DISORDER #World
- one’s sense of the reality of the outside world
is temporarily lost; detached reality
- the external world is perceived as strange and
new in various ways, may also occur
- the feeling puzzles the experiencers: the
changed condition is perceived as unreal, and as
discontinuous with his or her previous ego-state
- people with derealization symptoms
experience the world as hazy and indistinct
- commonly described as isolated, lifeless,
strange, and unfamiliar; oneself and others are
perceived as ‘automatons,’ behaving
mechanically, without initiative or self-control
- feeling as though they are living in a dream or
movie
DEPERSONALIZATION DISORDER #Self
- one’s sense of one’s own self and one’s own
reality is temporarily lost, but reality testing
remains intact
- similar with derealization, is commonly
described as isolated, lifeless, strange, and
unfamiliar; oneself and others are perceived as
‘automatons,’ behaving mechanically, without
initiative or self-control
- feeling as though they are living in a dream or
movie
- emotional experiences are attenuated or
reduced during depersonalization, both at the
subjective level and at the level of neural and
autonomic activity that normally accompanies
emotional responses to threatening or
unpleasant emotional stimuli
- ex. after viewing an emotional video clip,
participants with depersonalization disorder
showed higher levels of subjective and objective
memory fragmentation than controls
- also, can be triggered by hyperventilation, a
common symptom of panic attacks
MEMORY FRAGMENTATION
- is marked by difficulties forming an accurate or
coherent narrative sequence of events, which is
consistent with earlier research suggesting that
time distortion is a key element of the
experience of depersonalization
PREVALENCE, AGE OF ONSET, AND GENDER
DIFFERENCES OF DP/DR
- average age of onset of 23
- occasional depersonalization/derealization
symptoms are not uncommon in a variety of
other disorders such as schizophrenia,
borderline personality disorder, panic disorder,
acute stress disorder, and posttraumatic stress
disorder
5 COMORBIDITIES OF
DEPERSONALIZATION/DEREALIZATION
DISORDER:
>> ANXIETY DISORDERS
>> MOOD DISORDERS
>> AVOIDANT PERSONALITY DISORDERS
>> BORDERLINE PERSONALITY DISORDERS
>> OBSESSIVE-COMPULSIVE PERSONALITY
DISORDERS
• PROFESSIONAL ASSISTANCE IN DEALING WITH
THE PRECIPITATING STRESSORS AND IN
REDUCING ANXIETY MAY BE HELPFUL
- there are no clearly effective treatments either
through medication or psychotherapy
(2) DISSOCIATIVE AMNESIA
RETROGRADE AMNESIA
- is the partial or total inability to recall or
identify previously acquired information or past
experiences
ANTEROGRADE AMNESIA

- is the partial or total inability to retain new
information
PERSISTENT AMNESIA
- may occur in several disorders, such as
dissociative amnesia and dissociative fugue;
may also result from traumatic brain injury or
diseases of the central nervous system
BRAIN PATHOLOGY
- caused by head injury/trauma, brain disease
- if amnesia is caused by this, it most often
involves failure to retain new information and
experiences (anterograde)
- the information contained in experience is not
registered and does not enter memory storage
DISSOCIATIVE AMNESIA
- usually limited to a failure to recall previously
stored personal information (retrograde
amnesia) when that failure cannot be accounted
for by ordinary forgetting
- gaps in memory most often occur following
intolerably stressful circumstances or
catastrophic events such as wartime combat
conditions, serious car accidents, suicide
attempts, or violent outbursts
- amnesic episodes usually last between a few
days and a few years; many people experience
- induce/bring on
only one such episode, some people have by sodium
multiple episodes in their lifetimes amytal/truth
serum
- apparently forgotten personal information is
still there beneath the level of consciousness, as
sometimes becomes apparent in interviews
conducted under hypnosis or narcosis
SODIUM AMYTAL/TRUTH SERUM
- is also a type of barbiturate, or downer
- used before for soldiers with the psychological
disturbance called shell shock
- this drug is no longer used as a truth serum
because subjects sometimes develop false
memories after the fact
TYPICAL DISSOCIATIVE AMNESIC
REACTIONS
- individuals cannot remember certain aspects
of their personal life history or important facts
about their identity
- yet their basic habit patterns/implicit memory
such as their abilities to read, talk, perform
skilled work, and so on remain intact, and they
seem normal aside from the memory deficit
- this explains that the only type of memory that
episodic- pertaining to
is affected is episodic events experienced
and autobiographical
autobiographical memory-
memory pertaining to personal
events experienced
- but other forms of memory such as semantic
(pertaining to language and concepts),
procedural (how to do things), and short-
term storage, seem usually to remain intact
- usually there is no difficulty encoding new - recovery from the fugue state occurs only after
information repeated questioning and reminders of who
they are

• THE PATTERN IN DISSOCIATIVE AMNESIA AND

DISSOCIATIVE FUGUE IS ESSENTIALLY SIMILAR
TO THAT IN-CONVERSION SYMPTOMS
- except that instead of avoiding some
DISSOCIATIVE FUGUE unpleasant situation by becoming physically
dysfunctional, a person unconsciously avoids
thoughts about the situation or, in the extreme,
leaves the scene

• PEOPLE EXPERIENCING DISSOCIATIVE

AMNESIA AND FUGUE ARE TYPICALLY FACED
#AnterogradeAmnesia #DifferentLifeStyle
WITH EXTREMELY UNPLEASANT SITUATIONS
#ShoudRemindWhoUR
FROM WHICH THEY SEE NO ACCEPTABLE WAY
#DidSomethingAndFoundItLaterOn
TO ESCAPE
- an amnesic state which is a defense by actual
- stress becomes so intolerable that large
flight, a person is not only amnesic for some or
segments of their personalities and all memory
all aspects of his or her past but also departs
of the stressful situations are suppressed
from home surroundings about personal
identity or even the assumption of a new
identity, although the identities do not alternate
as they do in dissociative identity disorder
- such individuals are unaware of memory loss
for prior stages of their life, but their memory
for what happens during the fugue state itself is
intact
- their behavior during the fugue state is usually
quite normal and unlikely to arouse suspicion
that something is wrong; but behavior during
the fugue state often reflects a rather different
lifestyle from the previous one
- days, weeks, or sometimes even years later,
such people may suddenly emerge from the
fugue state and find themselves in a strange
place, working in a new occupation, with no
idea how they got there
 by ordinary forgetting; and they may have an
amnesia when they change their personality,
but this amnesia is not always symmetrical; that

MEMORY AND INTELLECTUAL DEFICITS IN is, some identities may know more about

DISSOCIATIVE AMNESIA AND FUGUE  certain alters than do other identities

- these individuals’ semantic knowledge - it is also a condition in which normally

(assessed via the vocabulary subtest of an IQ integrated aspects of memory, identity, and

test) seems to be generally intact consciousness are no longer integrated

- primary deficit these individuals exhibit is their - each identity may appear to have a different

compromised episodic or autobiographical personal history, self-image, and name,

memory although there are some identities that are only

- using brain imaging, it confirmed that when partially distinct and independent from other

people with dissociative amnesia are presented identities

with autobiographical memory tasks, they show - alters are not in any meaningful sense

reduced activation in their right frontal and personalities but rather reflect a failure to

temporal brain areas relative to normal controls integrate various aspects of a person’s identity,

doing the same kinds of tasks consciousness, and memory

- the problem is not having more than one

DISSOCIATIVE IDENTITY DISORDER personality; it is having less than one

/DID
HOST IDENTITY
- the one identity that is most frequently
encountered and carries the person’s real name
- the host is not the original identity, and it may
or may not be the best-adjusted identity

ALTER IDENTITIES
- formerly known as multiple personality
- may differ in striking ways involving gender,
disorder, but abandoned it since it had
age, handedness, handwriting, sexual
misleading connotations, suggesting multiple
orientation, prescription for eyeglasses,
occupancy of space, time, and people’s bodies
predominant affect, foreign languages spoken,
by differing, but fully organized and coherent,
and general knowledge
personalities
- ex. the movie entitled split
- it is a dramatic dissociative disorder in which a
patient manifests two or more distinct identities Even though Identity 2 could
there seems to be no not consciously recall the list
that alternate in some way in taking control of transfer to Identity 2 of words, Identity 2 would
of what was learned learn that list more rapidly
behavior by Identity 1 than a brand-new list of
words, an outcome that
- there is also an inability to recall important suggests the operation of
implicit memory
personal information that cannot be explained
but some of them does not recall implicit
informations because one identity is

• NEEDS AND BEHAVIORS INHIBITED IN THE
PRIMARY OR HOST IDENTITY ARE USUALLY
LIBERALLY DISPLAYED BY ONE OR MORE ALTER
IDENTITIES
8 ADDITIONAL SYMPTOMS OF DID
- depression
- self-mutilation/self-harm
- frequent suicidal ideation and attempts
- erratic/non consistent behavior
- headaches
- hallucinations
- posttraumatic symptoms
- other amnesic and fugue symptoms
• THE NUMBER OF ALTER IDENTITIES IN DID
VARIES TREMENDOUSLY AND HAS INCREASED
OVER TIME
- 50 % now show over 10 identities with some
respondents claiming as many as a hundred
- another recent trend is that many of the
reported cases of DID now include more
unusual and even bizarre identities than in the
past (such as being an animal) and more highly
implausible backgrounds (e.g., ritualized satanic
abuse in childhood)

PREVALENCE, AGE OF ONSET, AND GENDER

DIFFERENCES OF SSD

- DID usually starts in childhood

- most patients are teens, 20s, or 30s at the time
of diagnosis
- three to nine times more females than males
are diagnosed as having the disorder
- females tend to have a larger number of alters
than do males

• GENDER DISCREPANCY IS DUE TO THE MUCH

GREATER PROPORTION OF CHILDHOOD SEXUAL
ABUSE AMONG FEMALES THAN AMONG MALES

COMORBIDITY OF DID

(1) DEPRESSIVE DISORDERS

(2) PTSD
- most common
(3) SUBSTANCE USE DISORDERS
(4) BORDERLINE PERSONALITY DISORDER
 >> SOCIOCOGNITIVE THEORY
- DID develops when
a highly suggestible person learns to adopt and
enact the roles of multiple identities, mostly
because clinicians have inadvertently suggested,
legitimized, and reinforced them
CAUSAL FACTORS OF HYPOCHONDRIASIS
- also, because these different identities are
>> POSTTRAUMATIC THEORY
geared to the individual’s own personal goals
- original major theory of how DID develops
- the sociocognitive perspective maintains that
- report memories of severe and horrific abuse
this is not done intentionally or consciously by
as children since DID starts from the child’s
the afflicted individual but, rather, occurs
attempt to cope with an overwhelming sense of
spontaneously with little or no awareness
hopelessness and powerlessness in the face of
repeated traumatic abuse
CHILDHOOD ABUSE
- the child may dissociate and escape into a
- childhood abuse has been claimed by some to
fantasy, becoming someone else and if it helps
lead to many different forms of
to alleviate some of the pain caused by the
psychopathology including depression, PTSD,
abuse it will be reinforced and occur again in the
eating disorders, somatic symptom disorders,
future; can lead to decreased pain sensitivity
and borderline personality disorder
- if the child is fantasy prone, and continues to
- childhood abuse may play a nonspecific role
stay fantasy prone over time, the child may
for many disorders, with other, more specific
unknowingly create different selves at different
factors determining which disorder develops
points
- only a subset of children who undergo >> SOCIOCULTURAL FACTORS IN
traumatic experiences are prone to fantasy or DISSOCIATIVE DISORDERS
self-hypnosis, which leads to the idea that a -
diathesis-stress model may be appropriate her,
and they are the ones who are easily
hypnotizable may have a diathesis for
developing DID, but that there is nothing
inherently pathological about being prone to
fantasy or readily hypnotizable

ALTHOUGH DID AND POSTTRAUMATIC STRESS

DISORDER CAUSAL FACTOR ARE THE SAME
- anxiety symptoms are more prominent in PTSD
than in DID, and dissociative symptoms are
more prominent in DID than in PTSD