2 An Overview of Somatoform Disorders Soma = BodyPreoccupation with health or appearancePhysical complaintsNo identifiable medical conditionTechnology Tip: The following website offers several pages, informational handouts and links to resources on somatoform disorders:
3 An Overview of Somatoform Disorders HypochondriasisSomatization disorderConversion disorderPain disorderBody dysmorphic disorder
4 Hypochondriasis: An Overview Clinical DescriptionAnxiety or fear of having a diseaseHigh comorbidity with anxiety/mood disordersFocus on bodily symptomsNormalMildVagueContrast this with illness phobia and the fear of developing a disease.Technology Tip: The University of Maryland Medical Center website offers more information on hypochondriasis:Technology Tip: The Bio-Behavioral Institute website offers more information on hypochondriasis:
5 Hypochondriasis: An Overview Clinical Description (cont.)Little benefit from medical reassuranceStrong disease convictionMisperceptions of symptomsChecking behaviorsHigh trait anxietyTeaching Tip: Have students participate in the following Instructor Resource Manual Activity: Understanding Hypochondriasis.
6 Hypochondriasis and Panic Disorder SimilaritiesFocus on bodily symptomsDifferences in hypochondriasis:Focus on long-term process of illnessConstant concernConstant medical treatment seekingWider range of symptomsPanic Disorder is marked by a focus on immediate consequences of symptoms, a decline in worry between attacks, and a decrease in treatment seeking once the individual is educated about the disorder.
7 Hypochondriasis: An Overview Statistics1% to 14% of medical patients6.7% median rateFemale : Male = 1:1Onset at any agePeaks: adolescence, middle age, elderlyChronic course
8 Culture-Specific Syndromes China – koro India – dhat Africa Pakistan HypochondriasisCulture-Specific SyndromesChina – koroIndia – dhatAfricaPakistanKoro – genitals retracting into the abdomen, does affect some females as wellDhat- concern about losing semen, symptoms include dizziness, weakness, fatigueAfrica – crawling sensation or heat in the headPakistan – burning sensation in hands or feet
9 Disorder of cognition or perception Physical signs and sensations HypochondriasisCausesDisorder of cognition or perceptionPhysical signs and sensationsFigure 6.1 Integrative model of causes in hypochondriasis (based on Warwick & Salkovskis, 1990).
10 Familial history of illness Genetics Modeling/learning Other factors HypochondriasisCausesFamilial history of illnessGeneticsModeling/learningOther factorsStressful life eventsHigh family disease incidence“Benefits” of illnessDiscussion Tip: Have students discuss the current state of the art in terms of diagnosis and ability to detect medical problems. How might one’s access to medical providers shape perceptions of illness? Confidence in diagnosis?
11 Hypochondriasis - Treatment PsychodynamicUncover unconscious conflictLimited efficacy dataEducational & SupportiveOngoing and sensitiveDetailed and repeated informationBeneficial for mild cases
12 Hypochondriasis - Treatment Cognitive-BehavioralIdentify and challenge misinterpretations“Symptom creation”Stress-reductionBest efficacy dataVs. medications (SSRI)Immediate and 1 year follow-up“Symptom creation” refers to demonstrating how intensity of symptoms changes when they’re attended to, or produced if focused on.
13 Somatization Disorder Clinical DescriptionLong history of physical complaintsSignificant impairmentConcern about symptoms, not meaningSymptoms = identity
14 Somatization Disorder StatisticsRare4.4%; 16.6% in medical settingsOnset = adolescenceFemale : male = ~2:1Unmarried, low SESChronic courseSomatization disorder is rare, and prevalence rates range from 4.4% (in a large city) to 20% of a large sample of primary care patients.
15 Somatization Disorder: Causes History of family illness or injuryLinks to antisocial personality disorderBehavioral inhibition systemImpulsivityNovelty-seekingProvocative sexual behaviorSocializationGender rolesLinks with ASPD- neurobiology may be the same or similar, but the manifestations are different via socialization and gender roles, which result in more dependence and somatization for females.In essence, persons with these disorders may possess a weak behavioral inhibition system (BIS) that does not control the behavioral activation system (BAS).The BAS is a brain system that underlies impulsivity, thrill-seeking behavior, and excitability, whereas the BIS is involved in sensitivity to threat or danger and avoidance of situations or cues suggesting that threat or danger is imminent. Many behaviors and traits associated with somatization disorder also seem to reflect short-term gain (i.e., active BAS) and insensitivity for long-term problems (i.e., weak BIS).
16 Somatization Disorder: Treatment No “cures”Cognitive-behavioral interventionsInitial reassuranceStress-reductionReduce frequency of help-seeking behaviors
17 Somatization Disorder: Treatment “Gatekeeper” physicianReduce visits to numerous specialistsConditioningReward positive health behaviorsPunish problem behaviorsRemove supportive consequencesRelationship with the gatekeeper physician has to be positive and supportive.
18 Physical malfunctioning sensory-motor areas Conversion DisorderClinical DescriptionPhysical malfunctioningsensory-motor areasLack physical or organic pathologyLack awareness“La belle indifference”Possible, but not alwaysIntact functioning“La belle indifference” indifferent attitude that may or may not be present in people with CD. May also be present in those with actual medical disorders.Teaching Tip: The movie Talladega Nights: The Story of Ricky Bobby with Will Farrell has a scene depicting “paralysis” after a car crash.
19 Conversion Disorder : Differential Diagnosis MalingeringIntentionally produced symptomsClear benefitNo precipitating stressful eventImpaired functionFactitious Disorder/Munchausen’sNo obvious benefitSick role?Technology Tip: Munchausen Syndrome and Factitious Disorders An interesting starting point for the exploration of Munchausen syndrome and factitious disorders.Technology Tip: Child Abuse: Statistics, Research, and Resources A good resource for current research and informational links related to child abuse.
20 Prevalence depends on setting Female > male Onset = adolescence Conversion DisorderStatisticsRarePrevalence depends on settingFemale > maleOnset = adolescenceChronic, intermittent courseConversion disorders are rare, and prevalence estimates in neurological settings range from 1 to 30%, whereas in epilepsy setting the range is between 10 and 20% of cases.
21 Cultural considerations Religious experiences Rituals Conversion DisorderSpecial populationsSoldiersChildrenBetter prognosis?Cultural considerationsReligious experiencesRitualsConversion reactions are not uncommon in soldiers exposed to combat. Symptoms often disappear, but return later in the same or similar form when a new stressor occurs.Conversion symptoms are common in some cultural and rural fundamental religious groups. However, the symptoms would not meet criteria for a disorder unless they persist and interfere with life functioning.
22 Conversion Disorder: Causes Freudian psychodynamic viewTrauma, conflict experienceRepression“Conversion” to physical symptomsPrimary gainAttention and supportSecondary gainPrimary Gain: reduction of anxiety through more acceptable meansSecondary Gain: attention from others, reduction in responsibilitiesTeaching Tip: Have students participate in the following Instructor Resource Manual Activity: When Have I Assumed the Sick Role?
23 Conversion Disorder: Causes BehavioralTraumatic event must be escapedAvoidance is not an optionSocial acceptability of illnessNegative reinforcementGuide students through the psychodynamic and behavioral views to show the similarities between the two models.
24 Conversion Disorder: Causes Family/Social/CulturalLow SESLimited disease knowledgeFamily history of illness
25 Conversion Disorder: Treatment Similar to somatization disorderAttending to traumaRemove secondary gainReduce supportive consequencesReward positive health behaviors
26 Pain DisorderClinical DescriptionPain in one or more areasSignificant impairmentEtiology may be physicalMaintained by psychological factors
27 Combined medical and psychological Pain DisorderStatisticsFairly common5% - 12%TreatmentCombined medical and psychologicalSee chapter 9 for a more detailed discussion of pain disorders and health psychology
28 Body Dysmorphic Disorder Clinical DescriptionPreoccupation with imagined defect in appearanceImpaired functionSocialOccupationalTechnology Tip: Visit the Mayo Clinic website for more information on BDD:Technology Tip: Visit the Los Angeles BDD Clinic website for more information on BDD:
29 Body Dysmorphic Disorder Clinical DescriptionFixation or avoidance of mirrorsSuicidal ideation and behaviorUnusual behaviorsIdeas of referenceChecking/compensating ritualsDelusional disorder: somatic type?Delusional disorder: somatic type will likely drop out of the DSM V, given the lack of difference between those with delusional and non-delusional BDD.
30 Body Dysmorphic Disorder Statistics1% to 15%Female : Male = ~1:1Different areas of focusOnset = early 20sMost remain singleLifelong, chronic course
31 Body Dysmorphic Disorder: Causes Little scientific knowledgeCultural imperativesBody sizeSkin colorSimilarities with OCDIntrusive thoughtsRitualsAge of onset and course
32 Body Dysmorphic Disorder: Treatment Similar to OCDMedications (SSRIs)Exposure and response preventionPlastic surgery is often unhelpfulAs many as 25% of persons requesting plastic surgery meet criteria for BDD. Those with BDD do not benefit from plastic surgery, and preoccupation with imagined ugliness may actually increase following plastic surgery.
33 An Overview of Dissociative Disorders Severe alterations or detachmentsNormal perceptual experiencesSignificant impairmentsIdentityMemoryConsciousnessDepersonalizationDerealizationDepersonalization – Distortion in perception of realityDerealization – Losing a sense of the external worldTechnology Tip: American Society for Clinical Hypnosis A good resource for research relevant to altered states of consciousness.Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Invited Hypnotist or Pain Specialist.
34 An Overview of Dissociative Disorders TypesDepersonalization DisorderDissociative AmnesiaDissociative FugueDissociative Trance DisorderDissociative Identity DisorderTechnology Tip: The following site offers information and connections to other web sites related to dissociative disorders.Technology Tip: International Society for the Study of Dissociation Offers information about diagnosis and treatment of dissociative disorders.Technology Tip: Also visit the Mayo Clinic site on dissociative disorders:
35 Depersonalization Disorder: An Overview Clinical DescriptionFeelings of unreality and detachmentSevere/frighteningDepersonalizationDerealizationSignificant impairmentTeaching Tip: Have students participate in the following Instructor Resource Manual Activity: "Normal" Dissociations
36 Depersonalization Disorder: An Overview Statistics0.8%Female : Male = ~1:1High comorbiditiesAnxiety and mood disordersOnset = ~ age 16Lifelong, chronic course
38 Depersonalization Disorder: Treatment Psychological treatments are unstudiedProzac appears ineffective
39 Psychogenic memory loss Generalized type Localized or selective type Dissociative AmnesiaDissociative AmnesiaPsychogenic memory lossGeneralized typeLocalized or selective typeGeneralized type – Inability to recall anything, including their identityLocalized or selective type – Failure to recall specific (usually traumatic) eventsTeaching Tip: Have students participate in the following activity from the Instructor Resource Manual: Video Activity: Abnormal Psychology, Inside/Out, Vol. 2.
40 Retrograde vs. anterograde “How’s” or “why’s” of travel Dissociative FugueDissociative Fugue:Flight or travelMemory lossRetrograde vs. anterograde“How’s” or “why’s” of travelAssumption of new identityGeneralized type – Inability to recall anything, including their identityLocalized or selective type – Failure to recall specific (usually traumatic) events
41 Dissociative Amnesia and Fugue StatisticsTends to occur in adulthoodRapid onsetRapid dissipationFemales > males
42 Dissociative Amnesia and Fugue Causes and TreatmentsLittle is knownTrauma and life stressTreatmentResolution without treatmentMemory returns
43 Dissociative Trance Disorder Clinical DescriptionDissociative symptomsSudden personality changesState is undesirableCultural/religious variationsTechnology Tip: Check out the following site for a case study of DTD:
44 Dissociative Trance Disorder: An Overview StatisticsFemale > maleCausesLife stressor or traumaTreatment?
45 Dissociative Identity Disorder (DID) Clinical DescriptionAmnesiaDissociation of personalityAdopt several new identities or “alters”2 to 100Average = 15Unique characteristicsHostSwitchAlters – The different identitiesHost – The identity that keeps other identities togetherSwitch – Quick transition from one personality to anotherTechnology Tip: Dr. Paul McHugh of Johns Hopkins discusses Multiple Personality Disorder also known as Dissociative Identity Disorder:http://www.psycom.net/mchugh.html
46 Demand characteristics Physiological measures Eye movements GSR EEG Can DID be Faked?Real vs. false memoriesSuggestibilityHypnosis studiesSimulated amnesiaDemand characteristicsPhysiological measuresEye movementsGSREEGTechnology Tip: Recovered Memories of Sexual Abuse A useful scholarly source of information and links related to recovered memories of sexual abuse.
47 Dissociative Identity Disorder (DID) Statistics1.5% (year)Female : male = 9:1Onset = childhoodHigh comorbidity ratesAxis IAxis IILifelong, chronic courseAxis I Anxiety, substance abuse, depressionAxis II Borderline personality disorder
48 Biological vulnerability Reactivity Hippocampus and amygdala DID: CausesCausesBiological vulnerabilityReactivityHippocampus and amygdalaSevere abuse/trauma historyLinks with PTSDHighly suggestibleAuto hypnotic modelTeaching Tip: The movies Sybil and The Three Faces of Eve provide depictions of DID.
49 DID: TreatmentSimilar to PTSD treatmentReintegration of identitiesIdentify and neutralize cues/triggersVisualizationCopingAntidepressant medications?
50 Future DirectionsPossible changes to the DSM-VReorganizationPhysical and psychological origins“Health anxiety disorder”BDD and OCDAxis I or II classification