1. Somatoform, Dissociative, and Factitious Disorders
Chapter 5
Psyc 303 Spring 2013

2. Chapter Outline Somatoform Disorders Dissociative Disorders
Factitious Disorders
Reviewing Learning Objectives
It is extremely common for individuals to experience physical symptoms without an organic cause, which accounts for visits to the primary care physician.
Somatoform disorders are defined by the presence of physical symptoms or concerns about illness that cannot be explained by an established medical or psychological disorder.
Biological, psychological, and environmental factors should be considered when evaluating the onset of somatoform disorders.
Dissociative disorders, the subject of controversy and thought to represent a culture-bound syndrome, tends to involve disruption of the consciousness, memory, identity, or perception.
It is important to both review empirical data related to the causes of dissociative disorders and also explore iatrogenic factors to fully understand the development of these disorders.
The concept of repressed/recovered memories is inconsistent with current findings; however, it is possible to display amnesia and create false memories regarding events before the age of six, including those around sexual abuse.
Malingering involves feigning illness for a secondary gain; factitious disorders involve the deliberate creation of symptoms for no apparent reason; and people with somatoform or dissociative disorder do not deliberately produce their symptoms.

3. Dissociative Disorders: Disruption in the usually integrated functions of conciousness, memory, identity, or perception; Long standing controversial diagnostic group
Dissociative Amnesia: due to psychological trauma
Dissociative Fugue: loss of personal identity and memory
Dissociative Identity Disorder: alternative personalities
Depersonalization Disorder: feelings of detachment from one’s body or mind

4. Factitious Disorders
Factitious Disorder: Intentional feigning of pysical or psych symptoms, to assume the sick role – unlike malingering: FD unaware why they would like to assume the sick role
Factititious Disorder by Proxy: Intentionally producing pysical or psych symptoms in, to assume the sick role by proxy

5. Numerous hospitalizations
People with factitious disorder often visit emergency rooms on the weekend or evening shifts to be evaluated by junior clinical staff.
Numerous hospitalizations
People with factitious disorder often visit emergency rooms on the weekend or evening shifts to be evaluated by junior clinical staff.
Numerous hospitalizations

6. Somatoform Disorders: Conditions in which physical symptoms or concerns about an illness cannot be explained by a medical or psychological disorder
Six different disorders:
Somatization disorder
Undifferentiated somatoform disorder
Conversion disorder
Pain disorder,
Hypochondriasis, and
Body dysmorphic disorder

7. Somatoform Disorders: Conditions in which physical symptoms or concerns about an illness cannot be explained by a medical or psychological disorder
Somatization disorder
Onset before age 30; a history of physical symptoms including pseudoneurological symptoms
4 pain +2 gastrointestinal + 1 sexual + 1 pseudoneurological
Undifferentiated somatoform disorder
6 months or more of one or more physical complaints including pseudoneurological
Conversion disorder: Solely pseudoneurological symptoms
Most common: Voluntary motor dysfunction
Impaired coordination, balance, paralysis, difficulty swallowing, loss of speech,
Most frequent: muscle weakness in legs…
Less common: Sensory dysfunction
Loss of touch or pain sensations; double vision or blindness, deafness, hallucinations…
Pseudoseizures

8. Somatoform Disorders: Conditions in which physical symptoms or concerns about an illness cannot be explained by a medical or psychological disorder
Somatization
Undifferentiated
Conversion
Pain disorder
Persistent pain symptoms, non-medical, lasted for more than 6 months
Hypochondriasis (NOTE THE DSM 5 CHANGE)
Preoccupation with fears of having a serious disease based on misinterpretation of bodily symptoms – Rule Out: delusional (Delusional D somatic type); only about appearance (BDD)
Body dysmorphic disorder (BDD)

9. DSM-5 Changes: Hypochondriasis replaced by two new disorders (eliminating the concept of medically unexplained symptoms)
1. SOMATIC SYMPTOM DISORDER:
Somatic symptoms about which they are excessively concerned, preoccupied or fearful.
These fears and behaviors cause significant distress and dysfunction, and
Although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate.

10. DSM-5 Changes: Hypochondriasis replaced by two new disorders (eliminating the concept of medically unexplained symptoms)
2. ILLNESS ANXIETY DISORDER
Have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them.
Like people with somatic symptom disorder, they are not easily reassured.
Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels.

11. Body Dysmorphic Disorder (BDD)
An overwhelming concern that some part of the body is ugly or misshapen
Dysmorphophobia
Flaw in appearance “imagined” or “very minor”
Most commonly worry about skin, hair, nose, and face
Women and BDD
High risk for suicide
Doctor shopping
Cosmetic surgery and dermatologic treatments
Appearance checking
Grooming rituals

12. How do somatoform disorders impact individuals?
10 to 15% of adults in U.S. report work disability as a result of chronic back pain
Only 33% of patients with conversion disorder work full- time
People with somatization work on average 7.8 days less than everyone else
BDD and hypochondriasis is a severe and chronic condition
BDD and serious social impairment
Remission rates varied
30-50 % recovery for somatization d (1 yr)
33-90% recovery for conversion d (3-5 yrs)
Medically unexplained physical symptoms make up % of PCP appointments
Doctor-shopping – increase in medical costs

13. Are certain populations more at risk for somatoform disorders?
Sex, race, & ethnicity
-Somatization disorder is reported more frequently by women
-Racial and ethnic breakdowns: higher percentage among African- Americans
-The use of sociocultural explanations (e.g., family and community problems)
Shenjing shuairuo – loosely translated, nerve weakness, a cultural variation of somatoform disorders found among the Chinese

14. Developmental issues to consider…
BDD & adolescence
During adolescence, one’s appearance is believed to be a measure of self-worth.
Adolescents with BDD experience suicidal ideation at 80.6%, and 44.5% actually attempt suicide.
Diagnostic criteria (consistent across all age groups)
Somatoform disorders (rare before adulthood)
Most common symptoms in adults
Voluntary motor dysfunction:
Most frequent: muscle weakness in legs…

15. Etiology Biological (brain malfunction vs. structural abnormalities)
Larger caudate nuclei
Psychodynamic (intrapsychic conflict, personality, and defense mechanisms)
Behavioral (modeling & reinforcement)
Environment (stress, sexual abuse, family separation/loss, family conflict/violence, & sexual assault)
Distorted cognitions (somatic amplification)
Inaccurate beliefs (prevalence of illness, symptoms, & treatment)

16. An Integrative Model of Somatoform Disorder
Figure 5.3
An Integrative Model of Somatoform Disorder
Not just one factor contributes to the development of these disorders. Therefore, it is best to incorporate the biological, psychological, social, and cultural factors when discussing the onset of somatoform disorders. Does the medical profession influence somatoform disorders? Why or why not?
Adapted from Kirmayer, L.J., & Looper, K.J., "Somatoform disorders." In Adult Psychopathology and Diagnosis, 5th Ed., by M. Hersen, S.M. Turner, & D.C. Beidel (Eds.), pp Copyright © 2007 John Wiley & Sons. Reproduced with permission of John Wiley & Sons, Inc.

17. Treatment “NOT” Without: Reluctance and Resistance
Challenges of getting people to reveal their symptoms to a professional (only 41% of patients with BDD reveal their symptoms to a physician)
Emphasis placed on physical symptoms
The refusal to believe one has a psychological problem in need of a psychological intervention
BDD viewed as a “physical problem” (e.g., I am dissatisfied with the shape of my nose; therefore I can get a rhinoplasty), instead of a psychiatric problem
The use of cosmetic surgery, dermatological treatments, etc., and BDD

18. Biological and Psychological Treatment Options
Medication
-Particularly anti-depressants, selective serotonin reuptake inhibitors (SSRIs), such as Prozac with BDD
Psychological
-Basic education of the mind-body connection when it comes to symptoms
-Cognitive behavioral therapy (CBT)