1. Somatoform and Dissociative Disorders
Chapter 5
Somatoform and Dissociative Disorders

2. Somatoform Disorders Soma – meaning “body”
Preoccupation with health and/or body appearance and functioning
No identifiable medical condition causing the physical complaints
Technology Tip: The following website offers several pages, informational handouts and links to resources on somatoform disorders:

3. Somatoform Disorders Types of DSM-IV-TR somatoform disorders
Hypochondriasis
Somatization disorder
Conversion disorder
Pain disorder
Body dysmorphic disorder

4. Hypochondriasis Clinical description
Physical complaints without a clear cause
Severe anxiety about the possibility of having a serious disease
Strong disease conviction
Medical reassurance does not seem to help
Technology Tip: The University of Maryland Medical Center website offers more information on hypochondriasis:

5. Hypochondriasis Statistics Culturally specific disorder
Prevalence estimated between 1% and 5%
Onset at any age
Sex ratio equal
Runs a chronic course
Culturally specific disorder
Koro
dhat
Technology Tip: The Bio-Behavioral Institute website offers more information on hypochondriasis:

6. Hypochondriasis: Causes and Treatment
Cognitive perceptual distortions
Familial history of illness
Treatment
Challenge illness-related misinterpretations
Provide more substantial and sensitive reassurance and education
Stress management and coping strategies
CBT
Antidepressants offer some help

7. FIGURE 5. 1 Integrative model of causes of hypochondriasis
FIGURE 5.1  Integrative model of causes of hypochondriasis. (Based on Warwick, H. M., & Salkovskis, P. M., Hypochondriasis. Behavior Research Therapy, 28, 105–117.)

8. Somatization Disorder
Clinical description
Extended history of physical complaints before age 30
Substantial impairment in social or occupational functioning
Concern about the symptoms, not what they might mean
Symptoms become the person’s identity
Somatization disorder is rare, and prevalence rates range from about 4% (in a large city) to over 20% of a large sample of primary care patients.

9. Somatization Disorder
Statistics
Rare condition
Easier diagnosis in DSM-IV-TR, >8 symptoms
Undifferentiated somatoform disorders <8 symptoms possible elimination in DSM-5
Onset usually in adolescence
Mostly affects unmarried, low SES women
Runs a chronic course

10. Somatization Disorder: Causes and Treatment
Familial history of illness
Relation with antisocial personality disorder
Weak neurobiologically based behavioral inhibition system
Antisocial personality disorder (ASPD) in men and somatization disorder women often occur together.

11. Somatization Disorder: Causes and Treatment)
CBT is the best treatment
Reduce the tendency to visit numerous medical specialists “doctor shopping”
Assign “gatekeeper” physician
Reduce supportive consequences of talk about physical symptoms

12. Pain Disorder Little is known about pain disorder
Related to somatoform disorder
Clear physical pain
DSM-5 proposed to make this disorder part of “Complex Symptom Disorder”
5% to 8% of the population my have this disorder
Symptoms are real to patient

13. Conversion Disorder Clinical description Physical malfunctioning
Paralysis, blindness or difficulty speaking (aphonia)
Lack physical or organic pathology
Malfunctioning often involves sensory-motor areas
Persons show “la belle indifference”
Retain most normal functions, but lack awareness
“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.

14. Conversion Disorder
DSM-5 proposal to change name to “Functional Neurological Disorder”
Malingering – faking
Factitious disorder
Teaching Tip: The movie Talladega Nights: The Story of Ricky Bobby with Will Farrell has a scene depicting “paralysis” after a car crash.

15. Conversion Disorder Statistics
Rare condition, with a chronic intermittent course
Comorbid with anxiety and mood disorders
Seen primarily in females
Onset usually in adolescence
Common in some cultural and/or religious groups

16. Conversion Disorder: Causes
Freudian psychodynamic view is still popular
Emphasis on the role of past trauma and conversion
Detachment from the trauma and negative reinforcement
Address primary/secondary gain

17. Questions
Little Albert was classically conditioned to fear rats. How was this accomplished? You will need to consult outside resources.
What is classical conditioning? You may need to look in your text.
What is meant by generalization? To what other objects was Little Albert’s fear generalized?
Who is the researcher in this clip? What do you know about him?
This classic research has given great insight into how phobias may develop. In your own words describe how you think this might happen?
What do you think about this type of research? Do you have any concerns about the ethics of conducting such research with children?
How long do you think Little Albert’s fears continued? Try to find information to confirm your answer.

18. Conversion Disorder: Treatment
Similar to somatization disorder
Core strategy is attending to the trauma
Remove sources of secondary gain
Reduce supportive consequences of talk about physical symptoms

19. Body Dysmorphic Disorder (BDD)
Clinical description
Preoccupation with imagined defect in appearance
Often display ideas of reference for imagined defect
Suicidal ideation and behavior are common
Technology Tip: Visit the Mayo Clinic website for more information on BDD:

20. Body Dysmorphic Disorder
Statistics
More far common than previously thought
4% to 28% of college students meet the criteria for this disorder
Seen equally in males and females
Onset usually between 14 and 19
Most remain single, and many seek out plastic surgeons
Usually runs a lifelong chronic course
Technology Tip: Visit the Los Angeles BDD Clinic website for more information on BDD:

21. Body Dysmorphic Disorder: Causes
Little is known – disorder tends to run in families
Shares similarities with obsessive-compulsive disorder

22. Body Dysmorphic Disorder: Treatment
Treatment parallels that for obsessive compulsive disorder
Medications (i.e., SSRIs) that work for OCD provide some relief
Exposure and response prevention is also helpful
Cultural example – Taijin Kyofusho
Plastic surgery is often unhelpful

23. An Overview of Dissociative Disorders
Involve severe alterations or detachments
Affect identity, memory, or consciousness
Depersonalization – distortion is perception of reality
Derealization – losing a sense of the external world
Technology Tip: The following site offers information and connections to other web sites related to dissociative disorders:

24. An Overview of Dissociative Disorders
Types of DSM-IV-TR dissociative disorders
Depersonalization disorder
Dissociative amnesia
Dissociative fugue
Dissociative trance disorder
Dissociative identity disorder
Technology Tip: International Society for the Study of Dissociation offers information about diagnosis and treatment of dissociative disorders.

25. Depersonalization Disorder: An Overview
Overview and defining features
Severe and frightening feelings of unreality and detachment
Feelings dominate and interfere with life functioning
Primary problem involves depersonalization and derealization
Technology Tip: Also visit the Mayo Clinic site on dissociative disorders:

26. Depersonalization Disorder: An Overview
Facts and statistics
High comorbidity with anxiety and mood disorders
0.8% of the population
Onset is typically around age 16
Usually runs a lifelong chronic course

27. Depersonalization Disorder: Causes and Treatment
Cognitive deficits in attention, short-term memory, spatial reasoning
Deficits related to tunnel vision and mind emptiness
Such persons are easily distracted
Treatment
Little is known

28. Dissociative Amnesia: An Overview
Includes several forms of psychogenic memory loss
Generalized vs. localized or selective type
Generalized type – Inability to recall anything, including their identity
Localized or selective type – Failure to recall specific (usually traumatic) events

29. Dissociative Fugue: An Overview
Fugue = flight
Related to dissociative amnesia – proposed in DSM-5 to be subtype of dissociative amnesia
Take off and find themselves in a new place
Unable to remember the past
Unable to remember how they arrived at new location
Often assume a new identity

30. Dissociative Amnesia and Fugue: Causes
Statistics
Usually begin in adulthood
Show rapid onset and dissipation
Causes
Little is known
Trauma and stress can serve as triggers

31. Dissociative Amnesia and Fugue: Treatment
Most get better without treatment
Most remember what they have forgotten

32. Dissociative Trance Disorder: An Overview
Clinical description
Symptoms resemble other dissociative disorders
Dissociative symptoms and sudden changes in personality
Changes often attributed to possession by a spirit
Presentation varies across cultures
Nigeria – vinvusa
Thailand – phii pob
Technology Tip: Check out the following site for a case study of DTD:

33. Dissociative Trance Disorder: Causes and Treatment
Often attributable to a life stressor or trauma
Treatment
Little is known

34. Dissociative Identity Disorder (DID): An Overview
Clinical description
Formerly known as multiple personality disorder
Defining feature is dissociation of personality
Adoption of several new identities (as many as 100; average is 15)
Identities display unique behaviors, voice, and postures
Technology Tip: Dr. Paul McHugh of Johns Hopkins discusses Multiple Personality Disorder, also known as Dissociative Identity Disorder:

35. Dissociative Identity Disorder (DID): An Overview
Unique aspects of DID
Alters – different identities or personalities
Host – the identity that keeps other identities together
Switch – quick transition from one personality to another
Technology Tip: Recovered Memories of Sexual Abuse A useful scholarly source of information and links related to recovered memories of sexual abuse.

36. Dissociative Identity Disorder (DID): An Overview
Statistics
Average number of identities is close to 15
Ratio of females to males is high (9:1)
Onset is almost always in childhood
High comorbidity rates & lifelong, chronic course
More common that previously thought: 3% to 6%

37. Dissociative Identity Disorder (DID): Causes
Histories of horrible, unspeakable, child abuse
Closely related to PTSD, possibly an extreme subtype
Mechanism to escape from the impact of trauma
Biological vulnerability possible
Real and false memories
Teaching Tip: The movies Sybil and The Three Faces of Eve provide depictions of DID.

38. “Multiple Personality Disorder: Robert Oxnam” 05:24

39. “Multiple Personality Disorder: Karen Overhill” 06:41

40. Dissociative Identity Disorder (DID): Treatment
Focus is on reintegration of identities
Identify and neutralize cues/triggers that provoke memories of trauma/dissociation
Patient must relive and confront the early trauma
Hypnosis

41. Diagnostic Considerations in Somatoform and Dissociative Disorders
Separating real problems from faking
Malingering – deliberately faking symptoms
False memories and recovered memory syndrome
Related conditions – factitious disorder
Factitious disorder by proxy

42. Summary of Somatoform and Dissociative Disorders
Features of somatoform disorders
Physical problems without on organic cause
Features of dissociative disorders
Extreme distortions in perception and memory
Well established treatments are generally lacking

43. DSM-5 Proposed Changes