Somatoform and Dissociative Disorders

Barlow and Durand Chapter 6

Somatoform Disorders

• Clinical Description – physical complaints without an apparent cause.

• Reassuring from physicians does not help because the threat seems so real

Comorbid Disorders with Hypochondriasis
• Anxiety Disorders • Mood Disorders

Characteristics of Hypochondriasis
• Anxiety that is expressed in a particular way – bodily symptom preoccupation • They come to the attention of MHPs only after having seen their family physician

DSM-IV-TR Differences between Hypochondriasis and illness phobia
• Illness Phobia • Afraid of getting the disease • Avoid places of perceived contagion
• Hypochondriasis • Anxious that they actually have the disease • Go to get checked and rechecked • No avoiding because they already have it

Illness Phobia and Hypochondriasis

DSM-IV-TR Differences Between Hypochondriasis and Panic Attacks
• Panic Attacks • Fear immediate Symptoms related to catastrophes • Continue to believe that Panic Attacks will kill them, but learn quickly to stop going to doctors • Focus on 10-15 SNS Sx that relate to Panic Attacks

• Hypochondriasis • Focus on long term processes of illness and disease (cancer AIDS) • Seek out many second and third opinions, but remain unconvinced and unreasured • Wide ranges of concerns

Statistics on Hypochondriasis
• 1-4% of medical patients are diagnosed with Hypochondriasis • Sex Ratio –

Process of Hypochondriasis
• 1. Physician must rule out • 2. Mental Health Professional must determine the • 3. Must be aware of

Causes of Hypochondriasis?

Causes of Hypochondriasis?

Treatment for Hypochondriasis
• Very little • CBT – focus on identifying and challenging illness related misinterpretations of physical sensations and showing patients how to create Sx by focusing attention on parts of the body

Treatment for Hypochondriasis
• Stress Management • Uncovering Unconscious conflicts (psychodynamic) – • Reassurance – extensive reassurance by

Somatization Disorder
• • • Used to be Clinical Description More impaired than hypochondriasis. Not so much afraid that they have a disease more concerned

Somatization Disorder Cont.
• They do not feel the urgency to take action • However, they feel continually ill or weak • Entire life revolves around the symptoms • They are not sure who they are without them - identity

Statistics on Somatization Disorder

Statistics on Somatization Disorder
• 2 to1 female • Comorbid disorders are often anxiety disorders and mood disorders • Chronic • Common and uniform throughout the world

Causes of Somatization Disorder?
• • • Minor – Minor – Heredity studies are very inconclusive • Behavior learned in a maladaptive family setting • A dysfunction in the

Interesting Similarities between ASPD and Somatization Disorder
• • • • • • • • • • ASPD Primarily male Early in life Chronic Lower SES Difficult to treat Marital Discord Drug/Alcohol abuse Suicide attempts Aggressive/Impulsive/L ack of emotion
• • • • • • • • • • Somatization Disorder Primarily female Early in life Chronic Lower SES Difficult to treat Marital discord Drug/Alcohol Abuse Suicide attempts Impulsive/Novelty seeking/Provocative Sexual Behavior

Treatment for Somatization Disorder
• • • • Difficult Provide Reduce Reduce

• Communication/Interaction Skills

Conversion Disorder
• Departs from somatization disorder because less pain symptoms and much more severe problems (hospitalizations) • Has to do with physical malfunctioning such as paralysis, blindness, aphonia –

Conversion Disorder
• Most suggest a neurological disease that affects the sensory nervous motor systems • Can effect

• Said the anxiety resulting form unconscious conflicts was converted to physical Sx to find expression. This way the individual could discharge some anxiety without experiencing it. • He also said

Conversion Disorder
• Sx often precipitated by stress • People with conversion disorder can usually function normally – but they are truly unaware of this ability • For example

• Faking for gain • This must not be present in order for any of these disorders to be diagnosed

Closely Related Disorders
• Factitious Disorder –

• No obvious gain • Sick Role and Attention

Fictitious Disorder by Proxy
• Munchausen Syndrome • Family member usually the mother makes child sick to get attention for herself (sympathy)

Statistics on Conversion Disorders
• Common comorbid disorder is somatization disorder • 1-30% of cases • 10-20% cases

Statistics on Conversion Disorders
• Primarily female • Frequent in males at times of extreme stress • Onset adolescence • Lower education • Lower SES

Causes of Conversion Disorders?
• Freud Said • 1. Experience trauma (unacceptable conflict) • 2. Person represses conflict • 3. Anxiety increases and threatens to emerge so person converts it into physical Sx • 4. Thereby relieves pressure of having to deal with it • Most tend to agree with this because we have no better alternative at this time

Treatment of Conversion Disorders
• Identify and attend to the traumatic or • Remove sources of secondary gain • Get rid of reinforcements – family needs to help here

Pain Disorder
• There may be initially a clear physical reason for the pain, but psychological factors maintain the pain • The pain is not better accounted for by a mood, anxiety, or psychotic disorder • The pain is real it hurts regardless of the cause

Body Dysmorphic Disorder (BDD)
• “imagined ugliness” • A preoccupation with some

BDD Cont.
• Clinical Description • Many people with this disorder become fixated with mirrors • They check over and over to see if there has been any change • Some avoid mirrors all together

BDD Cont.
• Suicide is frequent with BDD • Ideas of Reference – • Can become house bound

DSM-IV-TR Differences Between OCD and BDD
• OCD • Patients for the most part know their thoughts are unreasonable or irrational • BDD • Patients believe their thoughts are totally reasonable and rational

Statistics on BDD

Statistics on BDD
• Caucasians, Asians, and Hispanics experience BDD more than African Americans • Slightly more • Age of onset • Usually reluctant to seek treatment

Culture and BDD
• Cultural practices everywhere mutilate or change the body in different ways • However, BDD occurs when the person goes against current cultural practices • It is not abnormal if it is culturally acceptable

Causes of BDD?
• Psychoanalytic –


Treatment of BDD
• There are only two treatments that have been found to be effective with BDD • SSRI’s – • Exposure and response prevention – CBT • 80% improved with CBT

BDD and Plastic Surgery
• Surgeons are supposed to assess for and deny patients with BDD • They should be consulting with psychologists • These patients do not benefit from surgery

BDD and Plastic Surgery
• • • They return for more surgery File malpractice suits Sometimes their perceived ugliness factor increases after surgery • 2-25% of patients that request plastic surgery may have BDD

Dissociative Disorders
• Individuals who feel detached from their surroundings almost as if day dreaming or living in slow motion • Most likely to happen after

Example of Dissociative Experience
• • • You stay up all night Cramming for an exam The next day you feel like you are living in slow motion • This is a dissociative state • Because you know the cause of it, it may not seem

Dissociative States
• Derealization – perception alters so you lose your sense of reality temporarily

• Depersonalization –

Depersonalization Disorder
• Feelings of unreality are so severe and frightening that they dominate an individual’s life and prevent normal functioning

Statistics on Depersonalization Disorder
• • • • Mean age of onset Chronic Slightly more Mood and Anxiety disorders

Dissociative Amnesia
• Two types

Generalized Amnesia
• People who are unable to remember anything, including who they are

Localized or Selective Amnesia
• A failure to recall specific events, usually traumatic, that occur during a specific period of time • Examples war or car wreck

Dissociative Fugue
• Memory loss revolves around a very specific incident – • Individual usually just take off and later find themselves in a new place, unable to remember how they got there or why

Dissociative Fugue
• During these trips people sometimes assume a new identity or at least become confused about their current one

Amnesia and Fugue
• Usually occur in adulthood • Different types occur in many cultures • Treatment – • Treatment can help increase personal coping skills and reduce stress

Dissociative Trance Disorder
• Associated with stress or trauma that is current • Very self explanatory –

Dissociative Trance Disorder
• Most common in women • In some cultural contexts this is not abnormal • Examples

Dissociative Trance Disorder
• When the state is undesirable then it is abnormal • Not common in western cultures • Among the most common forms of

Dissociative Identity Disorder (DID)
• Multiple Personalities • May adopt as many as 100 simultaneously existing personalities • Some are complete with their own behaviors, tones of voices, an gestures • These personalities are referred to as alters

Dissociative Identity Disorder (DID)
• The DSM-IV-TR states the person must have amnesia • Aspects of the personality are dissociated from the person

DID Characteristics
• The person who becomes the patient is the host • The first personality to seek treatment seldom is the original personality of the person • Many of at least one impulsive alter who handles sexuality and generates income

DID Characteristics
• Cross-gendered alters are not uncommon • The transition from one personality to another is called a switch • Switches are usually instantaneous (though usually made more dramatic in movies)

DID Characteristics
• Physical transformations can occur such as posture, facial expressions, patterns of facial wrinkles, even physical disabilities and changes in handedness

Can DID Be Faked?
• Yes it can be faked (Hillside Strangler) • How can you tell if the individual is faking DID? • Suggest something that DID personalities usually do not do, and see if the individual creates this

Can DID Be Faked?
• Look back before they were motivated to get whatever it is they are trying to get now

• Look for differences in personalities that are hard to fake like heart rate, handedness, eye movement differences, visual acuity, GSR, EEG, fMRI

Statistics on DID
• • • Average number of alters is 9 to 1 Childhood onset (as young as 4 usually around 7)

Statistics on DID
• Almost all cases of DID have included horrific child abuse (97%) • DID has auditory hallucinations at times however the voices are reported to come from inside the head not outside like in psychotic states – also they are aware that these are hallucinations

Statistics on DID
• Studies show that DID occurs in a variety of cultures • 21 different countries have reported cases of DID

Causes of DID?
• • Child abuse 97% DID is rooted in a natural tendency to escape or dissociate from negative effects of severe trauma or abuse • Lack of social support in these cases • Suggestibility

Research is Showing
• DID to be a very extreme subtype of PTSD

Treatment for DID
• Long-term Psychotherapy • 5 of 20 achieve full integration of personalities • Therapy works on identifying cues and triggers that provoke memories of the trauma and neutralize them

Treatment for DID
• Confront and relive the traumas in order to gain control (PTSD) • Relive until it is simply a terrible memory rather than a current event

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