1. Somatic Symptom Disorders and Dissociative Disorders
Chapter 5
Somatic Symptom Disorders and Dissociative Disorders

2. Outline Somatic Symptom Disorders Dissociative Disorders
Illness Anxiety Disorder
Conversion Disorder
Factitious Disorder
Psychological factors affecting medical condition
Dissociative Disorders
Depersonalization/Derealization Disorder
Dissociative Amnesia
Dissociative Identity Disorder

4. Somatic Symptom Disorders
Illness Anxiety Disorder
Conversion Disorder
(Functional Neurological Symptom Disorder)
Factitious Disorder
Psychological factors affecting medical conditions

5. Overview of Somatic Symptom Disorders
Soma – meaning “body”
Preoccupation with health and/or body appearance and functioning
Often associated with stress and anxiety
No identifiable medical condition causing the physical complaints
Psychological disorders masquerading as physical symptoms

7. Somatic Symptom Disorder
Overview and defining features
Presence of one or more medically unexplained symptoms
Substantial impairment in social or occupational functioning
Concern about the symptoms, not as much about what they might mean
In severe cases, symptoms become the person’s identity
Very similar to DSM-IV Somatization Disorder
DISTINGUISHING FROM ILLNESS ANXIETY DISORDER: This is confusing, because both disorders may involve anxiety about physical health. In illness anxiety disorder, symptoms are very mild or absent, and the main problem is the high level of worry about having a serious illness. In somatic symptom disorder, symptoms are definitively present. The main problem is preoccupation with symptoms themselves (e.g. always researching symptos, constantly talking about symptoms or complaining about physical symptoms), not a concern that they might be indicative of a serious illness.
Somatic symptom 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.

8. DSM-5 Criteria: Somatic Symptom Disorder

9. Somatic Symptom Disorder w/ predominant pain
Type of somatic symptom disorder, previously classified as “Pain Disorder”
Little is known about origin
Clear physical pain that is medically unexplained
But the symptoms are real to the patient
Often develops after an accident or illness that has caused genuine pain
5% to 8% of the population my have this disorder
May begin at any age; more women than men

10. Somatic Symptom Disorder: Statistics
Relatively rare condition
Onset usually in adolescence
More likely to affect unmarried, low SES women
Runs a chronic course
Research to date is limited due to recent redefinition of the disorder in DSM

11. Somatic Symptom Disorder: Causes
Little is known
Familial history of illness
Stressful life events
Sensitivity to physical sensations
Experience suggesting that there are benefits to illness (e.g., attention)

12. Somatic Symptom Disorder: Treatment
CBT is the best treatment
Reduce the tendency to visit numerous medical specialists “doctor shopping”
Assign “gatekeeper” physician
Responsible for determining whether each new complaint merits additional medical advice
Reduce secondary gains of frequent complaining (i.e., sympathy from others)
Discourage family from checking in about physical symptoms, offering help with tasks, etc., in order to eliminate the positive consequences of focusing on one’s symptoms

14. Illness Anxiety Disorder
Overview and defining features
Physical complaints without a clear cause
Often unrealistically interpret “normal” bodily symptoms as signs of serious illness
Severe anxiety about the possibility of having a serious disease
Helpful indicator to distinguish from Somatic Symptom Disorder (more focus on anxiety vs. chronic symptoms)
Strong disease conviction
Medical reassurance does not seem to help
Very similar to DSM-IV Hypochondriasis

15. DSM-5 Criteria: Illness Anxiety Disorder

16. Illness Anxiety Disorder
Statistics
Prevalence estimated between 1% and 5%
Onset at any age
Sex ratio equal
Runs a chronic course
Culturally specific disorders similar to Illness Anxiety Disorder
Koro – fear in some Asian cultures of genitals retracting into the abdomen
Dhat – symptoms like dizziness, weakness, and fatigue are attributed to semen loss in some Indian cultures

17. Illness Anxiety Disorder
Causes
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 is generally effective
Antidepressants offer some help

18. Integrative Model of Illness Anxiety Disorder Causes

20. Conversion Disorder Overview and defining features
Also known as Functional Neurological Symptom Disorder
Physical malfunctioning
e.g., paralysis, blindness or difficulty speaking (aphonia)
Lack physical or organic pathology
Malfunctioning often involves sensory-motor areas
Persons show “la belle indifference”
Indifferent attitude
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.

21. DSM-5 Criteria: Conversion Disorder

22. 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

23. Conversion Disorder: Causes
Not well understood
Freudian psychodynamic view is still common, but unsubstantiated
Past trauma or unconscious conflict is “converted” to a more acceptable manifestation (i.e., physical symptoms)
Primary/secondary gains
Freud thought primary gain was the escape from dealing with conflict
Secondary gains include attention, sympathy, etc.

24. Conversion Disorder: Treatment
Similar to somatization disorder
If onset after a trauma, may need to process trauma or treat posttraumatic symptoms
Remove sources of secondary gain
Reduce supportive consequences of talk about physical symptoms

25. Conversion Disorder

27. Factitious Disorders Overview and defining features
Purposely faking physical symptoms
May actually induce physical symptoms or just pretend to have them
Motivation for the behavior is to assume the sick role
No obvious external gains
Distinguished from “malingering,” in which physical symptoms are faked for the purpose of achieving a concrete objective (e.g., getting paid time off, avoiding military service)

28. DSM-5 Criteria: Factitious Disorder

29. Factitious Disorder
Most common among people with the following factors:
As children, they received extensive medical treatment for a true physical disorder
Experienced family problems or physical or emotional abuse in childhood
Carry a grudge against the medical profession
Have worked as a nurse, laboratory technician, or medical aide
Have an underlying personality problem, such as extreme dependence

30. Factitious Disorder Imposed on Another
More commonly known as Munchausen Syndrome by proxy
A caregiver makes up or produces physical illnesses in their child
Purpose is to receive attention or sympathy
When children are removed from the caregiver, their symptoms disappear
Dependable treatments have not yet been developed
Psychotherapists and medical practitioners often become annoyed or angry at such patients

32. Psychological Factors Affecting Medical Condition
Diagnostic label useful for clinicians
Indicates that psychological variables may be impacting a medical issue
Examples:
Chronic anxiety attacks worsening asthma
Needle phobia making it impossible to get important bloodwork done

34. Dissociative Disorders
Depersonalization/Derealization Disorder
Dissociative Amnesia
Dissociative Identity Disorder

35. Dissociative Disorders
Involve severe alterations or detachments
Affect identity, memory, or consciousness
But no physical causes
Depersonalization – distortion is perception of one’s own body or experience (e.g., feeling like your own body isn’t real)
Derealization – losing a sense of the external world (e.g., sense of living in a dream)

37. Depersonalization/Derealization Disorder
Overview and defining features
Severe and frightening feelings of unreality and detachment (persistent and causes impairment)
i.e., feel as if becoming separated from their body (and/or surroundings) and are observing themselves from outside
The central symptom is persistent and recurrent episodes of depersonalization, which is a change in one’s experience of the self in which one’s mental functioning or body feels unreal or foreign
Depersonalization is often accompanied by derealization – the feeling that the external world, too, is unreal and strange

38. DSM-5 Criteria: Depersonalization/Derealization Disorder

39. Depersonalization/Derealization Disorder: Statistics
High comorbidity with anxiety and mood disorders
1-2% of the population
Onset is typically in adolescence
Tends to come on suddenly and usually runs a lifelong chronic course
Having a history of trauma makes this disorder more likely to manifest

40. Depersonalization/Derealization Disorder
Causes
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 due to limited research

42. Dissociative Amnesia Overview and defining features
People with dissociative amnesia are unable to recall important information, usually of an upsetting nature, about their lives
The loss of memory is much more extensive than normal forgetting and is not caused by organic factors
Very often an episode of amnesia is directly triggered by a specific upsetting event
Two Subtypes
Generalized – inability to recall anything, including identity
Localized/Selective – failure to recall specific events

43. DSM-5 Disorder Criteria: Dissociative Amnesia

44. Dissociative Amnesia May include “dissociative fugue”
During the amnestic episode, the person travels or wanders, sometimes assuming a new identify in a different place
Unable to remember how or why one has ended up in a new place
It usually follows a severely stressful event, although personal stress may also trigger it
Individuals tend to regain most or all of their memories and never have a recurrence

45. Dissociative Amnesia Statistics Causes Treatment
Usually begin in adulthood
Show rapid onset and dissipation
Causes
Little is known
Trauma and stress can serve as triggers
Treatment
Most get better without treatment (and rarely have a recurrence)
Most remember what they have forgotten

47. Dissociative Identity Disorder
Overview and defining features
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 memories, behaviors, thoughts, emotions, voice, and postures

48. DSM-5 Disorder Criteria: Dissociative Identity Disorder

49. Dissociative Identity Disorder
Characteristics
Host – the identity that keeps other identities together (appears more often than others)
Alters – different identities or personalities
Switching – quick (sometimes dramatic) transition from one personality to another

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

51. Dissociative Identity Disorder: Causes
Typically linked to a history of severe, chronic trauma, often abuse in childhood
Mechanism to escape from the impact of trauma
Closely related to PTSD, possibly an extreme subtype
Biological vulnerability possible
Real and false memories

52. Dissociative Identity Disorder: Treatment
Focus is on reintegration of identities
Identify and neutralize cues/triggers that provoke memories of trauma/dissociation
Patient may have to relive and confront the early trauma
Hypnosis (controversial – can result in false memories)

53. Dissociative Identity Disorder: False Memories
Fairly easy to create false memories through suggestibility
Interest in repressed memories has led to some patients thinking they have repressed memories of abuse which are later shown to be false, but can be very damaging to patients and their families
Therapists need to be well trained in memory function and be careful not to suggest an untrue history by mistake

55. Summary of Somatic Symptom Disorders and Dissociative Disorders
Features of somatic symptom disorders
Physical problems without on organic cause
Features of dissociative disorders
Extreme distortions in perception and memory
Well established treatments are generally lacking